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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602177
Report Date: 06/13/2024
Date Signed: 06/13/2024 11:22:22 PM


Document Has Been Signed on 06/13/2024 11:22 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: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: 5DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Marife OrdonioTIME COMPLETED:
04:00 PM
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On 06/13/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manger Marife Ordonio and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden ages 60 and above. The facility is approved for (2) hospice residents. Currently, the facility has (1) residents in hospice care.

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

LPA and house manager 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 was 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 105.6 degree F. A comfortable temperature of 72 degree F 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 extinguisher were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 06/02/24. A landline telephone was in working condition. A review of staff CPR/First Aid training is current.

Evaluation Report Continues LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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: LIVE WELL RESIDENTIAL CARE
FACILITY NUMBER: 198602177
VISIT DATE: 06/13/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 12/08/23 - 12/28/24. The facility is not current on Community Care Licensing annual dues with an open balance of $495.00 due by 06/27/24. The facility has a current Administrator Certificate #6035175740 Exp. 05/21/25 for Jovanne Anguluan.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#5 (S1-S5) personnel files revealed to be complete.

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.

An exit interview was conducted, and a copy of this report was provided to house manager, Marife Ordonio.


SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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