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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602177
Report Date: 06/23/2022
Date Signed: 06/24/2022 06:47:48 AM


Document Has Been Signed on 06/24/2022 06:47 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:LIVE WELL RESIDENTIAL CAREFACILITY NUMBER:
198602177
ADMINISTRATOR:ANGULUAN, JOVANNEFACILITY TYPE:
740
ADDRESS:211 E CLARION DRIVETELEPHONE:
(310) 435-8608
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 6DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Jovanne AnguluanTIME COMPLETED:
03:59 PM
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On 06/23/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Jovanne Anguluan and explained the purpose of today’s visit. The facility is licensed for six (6) residents and currently has six (6) residents. The facility is licensed for a hospice waiver on file and currently has two (2) resident on hospice.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.7 F. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. Fire drill was conducted on 06/11/22.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LIVE WELL RESIDENTIAL CARE
FACILITY NUMBER: 198602177
VISIT DATE: 06/23/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident test results and vaccination records.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Jovanne Anguluan.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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