198320009-4-11-2024-11-AS-PSCT-D48QT3-20240411122629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320009
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:26:33 PM

Document Has Been Signed on 04/11/2024 12:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	WELLNESS WORLD LLC		FACILITY NUMBER:	198320009
ADMINISTRATOR:	GOMEZ, ELIZABETH C		FACILITY TYPE:	740
ADDRESS:	1119 E 215TH PL		TELEPHONE:	(213) 568-7298
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Elizabeth Gomez		TIME COMPLETED:	01:00 PM

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On 4/11/24, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA was met by Elizabeth Gomez, Administrator, and the purpose of the visit was explained. The facility is licensed to serve residents aged 60 and over, of which six (6) may be non-ambulatory, one (1) may be bedridden, and hospice waiver for 3. Currently, the facility has (6) residents that include: (2) non-ambulatory, and (4) ambulatory resident. The facilities’ annual fees are current as well as the liability insurance.

The facility is a two-story residential home located in a residential neighborhood. The facility is located on the first floor, and consists of (3) resident bedrooms, (2) bathrooms, living room, dining room, kitchen, activity room, garage/ storage and backyard with patio cover and tables and chairs.

LPA conducted a records review of (6) client records, (4) staff records, and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (6) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

At 10:00am, LPA toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 118.9F. A comfortable temperature is maintained in the facility.

Report continued on LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELLNESS WORLD LLC	FACILITY NUMBER: 198320009
	VISIT DATE: 04/11/2024

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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The fire extinguishers were charged and last inspected on 11/30/2023. Smoke/ Carbon Monoxide detectors were operable. The last fire/emergency drill was conducted on 04/20/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Exit interview held. A copy of the report was provided to Elizabeth Gomez, Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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