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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005672
Report Date: 10/14/2022
Date Signed: 10/14/2022 01:42:43 PM


Document Has Been Signed on 10/14/2022 01:42 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:WELLINGTON, THEFACILITY NUMBER:
306005672
ADMINISTRATOR:THOMAS, JOHNATHANFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAYTELEPHONE:
(949) 458-2311
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:160CENSUS: 115DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Jonathan Thomas, Jennfier OrtegaTIME COMPLETED:
01:50 PM
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On 10/14/2022 at 9:23am, Licensing Program Analyst (LPA) Jessica Cho arrived at The Wellington to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on Infection Control. At 9:25am, LPA Cho entered the facility and was greeted by Receptionist Stephanie Chavez and completed the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. At 9:30am, LPA was greeted by Regional Operations Specialist Tami Ojwang and was taken to the Conference Room. LPA met with Executive Director (ED) Jonathan Thomas at 9:55am in the Conference Room. The facility is licensed for 160 and comprised of 24 ambulatory, 136 non-ambulatory of which 16 may be bedridden and has a hospice waiver for 20. As of today, there are 115 residents living in the facility and 4 are receiving hospice care.

At 10:30am, LPA Cho was introduced to Assistant Executive Director (AED) Jennifer Ortega in the Conference Room. ED Thomas endorsed AED Ortega to assist LPA with the tour. At 10:45am, LPA Cho conducted a tour of the physical plant along with AED Ortega. This is a five story facility with Assisted Living (AL) and Independent Living (IL). The even numbers are AL and odd numbers are IL. LPA Cho inspected the AL and all common areas located on the 2nd floor. The following common areas were observed: Conference Room, Fitness, Health Services, Beauty Salon, Card Room, Bistro, Staff Break Room, Arts/Crafts, Grand Parlor, bathrooms, swimming pool, and Club House. The Mail Room, Computer Room, Kitchen, Dining Room, and the Employee Office were inspected on the 4th floor. There are a total of 117 AL apartments and 148 AL bathrooms. Out of the 117 AL apartments, LPA Cho randomly selected and inspected a total 16 apartments/bathrooms. Two apartments were inspected on Level 1, two apartments on Level 2, five apartments on Level 3, six apartments on Level 4, and one apartment on Level 5. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly and grab bars were secure. The showers were free of mold/mildew, and non-skid mats were in place.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WELLINGTON, THE
FACILITY NUMBER: 306005672
VISIT DATE: 10/14/2022
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Resident bath towels and personal hygiene supplies were adequately stocked including hand soaps. Hand washing signs were observed in all public/shared bathrooms including paper towels. LPA Cho tested the hot water temperature in 16 resident bathrooms and the temperatures measured between the ranges of 118.5 to 120.7 degrees Fahrenheit. Four out of the sixteen bathrooms measured above 120 degrees Fahrenheit. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Facility has ample back-up emergency food and water supply. The auditory devices were operational. The fire extinguishers were mounted, fully charged, and serviced by Fire Masters on 04/04/2022. The smoke/carbon monoxide detectors were tested by Johnson. Per ED, the smoke detectors were tested and operational. ED was unable to provide the inspection report from Johnson (JCI). ED to provide the report once obtained. LPA Cho and AED Ortega tested the carbon monoxide detectors on the route to inspect the 16 resident bedrooms and were tested operational except the carbon monoxide next to the apartment for Resident 5 (R5). Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. LPA observed a courtyard with a putting green. There was shading and sufficient seating for residents, and the walkways around the facility were clear of hazards. All exit gates were self-closing and self-latching.

LPA observed the required COVID-19 precautionary signs on the front door. The Complaint Poster (PUB475) did not meet the size requirement which measured at 11"x17." LPA Cho observed the outdated Emergency and Disaster Plan for Residential Care for the Elderly (LIC610E) posted on the Employee Office, and ED was advised to update the information using the current LIC610E form per the Provider Information Notice (PIN 22-02-ASC) released on 01/06/2022. The facility had sufficient PPEs and had a first aid kit.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued. An exit interview was conducted with Executive Director Jonathan Thomas, and a copy of this report along with the LIC811s were provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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