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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602851
Report Date: 08/05/2024
Date Signed: 08/05/2024 11:20:13 AM


Document Has Been Signed on 08/05/2024 11:20 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:LIVING WELL #3FACILITY NUMBER:
198602851
ADMINISTRATOR:JUSTICE, RICHARDFACILITY TYPE:
735
ADDRESS:12825 BELHAVEN AVETELEPHONE:
(310) 933-8837
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY:4CENSUS: 0DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Karen Howell, AdministratorTIME COMPLETED:
11:20 AM
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On 08/5/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CARE Inspection Tool. LPA met with Administrator, Karon Howell and explained the purpose of today’s visit. The facility is licensed to serve developmentally disabled residents ages 18-59 years old. During the time of visit there are no clients nor staff present.


LPA Shirley and Karon toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathroom, living room, kitchen, dining area, garage used as an office. The laundry room is in the hallway off of the kitchen. Facility maintains all required posting throughout the facility. LPA Shirley reviewed the surety bond.

All bedrooms were toured. Bedrooms 1-4 contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Karon toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications would be locked and stored in the file cabinet in the hallway and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 109.4 degrees Fahrenheit.

The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

con'd on 809-C

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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: LIVING WELL #3
FACILITY NUMBER: 198602851
VISIT DATE: 08/05/2024
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LPA Shirley and Karon walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen, living room and den. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

There were no deficiencies observed.


An exit interview was conducted, and a copy of this report was provided to Administrator, Karon Howell.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
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