<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801979
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:31:38 PM


Document Has Been Signed on 07/28/2023 03:31 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:WELLNESS CARE SENIOR LIVINGFACILITY NUMBER:
565801979
ADMINISTRATOR:MARIA HERNANDEZFACILITY TYPE:
740
ADDRESS:158 ROCKAWAY ROADTELEPHONE:
(805) 649-5143
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:56CENSUS: 28DATE:
07/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maria HernandezTIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Esther Cotez conducted an unannounced Case Management - Incident inspection pertaining to a self reported Unusual Incident/Injury Report (LIC 624) received on 07/19/2023. The LPA met with Administrator Maria Hernandez at 11:50 AM and informed them the reason for the visit.

The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 07/17/2023 regarding Resident #1 (R1). During today's inspection, the LPA toured the facility with the administrator at 1:00 PM and conducted interviews with one staff, R1, and two of R1s family members between 1:20 PM and 2:30 PM. The LPA interviewed the Administrator Maria Hernandez throughout the visit. At 2:45 PM the LPA reviewed facility records and obtained copies of pertinent records.

At 12:00 PM, the LPA reviewed an audio recording with Administrator Maria Hernandez and obtained a copy of the requested recording.

No immediate health and safety concerns were observed during today's inspection. The LPA has determined further investigation is needed. The report was issued to Administrator Maria Hernandez.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1