198602177-6-15-2023-11-AS-PSCT-CSTTLA-20230615144912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602177
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:49:22 PM

Document Has Been Signed on 06/15/2023 02:49 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	LIVE WELL RESIDENTIAL CARE		FACILITY NUMBER:	198602177
ADMINISTRATOR:	ANGULUAN, JOVANNE		FACILITY TYPE:	740
ADDRESS:	211 E CLARION DRIVE		TELEPHONE:	(310) 435-8608
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 5	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	ANGULUAN, JOVANNE		TIME COMPLETED:	03:00 PM

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On 06/15/23, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jovanne Anguluan, Administrator, and explained the purpose of today’s visit. The facility is licensed for six (6) non-ambulatory residents aged 60 and over, of which one (1) may be bedridden, with a hospice waiver for two (2). Currently, the home has (5) clients. The clients are private pay clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facilities annual fees are current.

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 conducted a records review of (5) client records, (6) staff records, and reviewed the facility disaster plan. The facility does not handle the clients cash resources. 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 (5) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

Report continued on LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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: 06/15/2023

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LPA and Marife Ordonio, caregiver, 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. LPA observe that the water temperature met Title 22 standards and measured at 115.5 F. A comfortable temperature 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 sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Fire extinguishers were charged, smoke and carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 04/19/2023.

Evaluation Report Continues on LIC 809-C

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 located 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 60-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.

An exit interview was conducted, and a copy of this report was provided to Jovanne Anguluan, Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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