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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801979
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:48:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:WELLNESS CARE SENIOR LIVINGFACILITY NUMBER:
565801979
ADMINISTRATOR:ALEIDA ALONSOFACILITY TYPE:
740
ADDRESS:158 ROCKAWAY ROADTELEPHONE:
(805) 649-5143
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:56CENSUS: 30DATE:
12/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Aleida AlonsoTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) JoAnn Rosales and Angel Ascencio conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Aleida Alonso.

During facility tour with staff Graciela Castillo at 11:44 am LPAs observed resident #1 (R1) alone in an office with the door partially open. LPAs observed clorox disinfecting wipes and a wrench in the office accessible to residents. During facility tour with staff Castillo starting at 11:48 am LPAs observed 3 razors, shampoo, lotion, after shave, windex and furniture polish in an unlocked staff room accessible to residents. Staff stated that the door is normally locked as it has a code. During facility tour with staff George Paniagua at 12:09 pm LPAs observed disinfectant deodorant in R2's room accessible to residents. During facility tour with staff Paniagua at 12:09 pm LPAs observed toothpaste, body wash, shampoo, conditioner, safety pins, wheat grass and insect repellent in R3's room accessible to residents. During facility tour with staff Paniagua at 12:15 pm LPAs observed clorox disinfecting wipes, toothpaste, after shave, deodorant, calmoseptine ointment, dry mouth oral rinse, listerine mouth wash, lotion and sunscreen in R4's room accessible to residents. A review of all resident records revealed that there are 8 residents in the facility that are at risk based on their dementia diagnosis if allowed direct access to personal grooming and hygiene items.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as a wrench and razors were observed accessible to residents which posed an immediate safety risk to persons in care.
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Type A
12/23/2021
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medication, nutritional supplements and toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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