565801979-9-19-2024-29-AS-TCAA-D99TUL-20240919150231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801979
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:04:02 PM

Document Has Been Signed on 09/19/2024 03:04 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WELLNESS CARE SENIOR LIVING		FACILITY NUMBER:	565801979
ADMINISTRATOR:	MARIA HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	158 ROCKAWAY ROAD		TELEPHONE:	(805) 649-5143
CITY:	OAK VIEW	STATE: CA	ZIP CODE:	93022
CAPACITY:	56	CENSUS: 19	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:52 AM
MET WITH:	Maria Hernandez		TIME COMPLETED:	03:20 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) Teresa Camara conducted an unannounced required annual visit at the facility. LPA met with the Administrator Maria Hernandez and explained the reason for the visit. LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure that there are no health and safety hazards. Smoke and carbon monoxide detectors were tested and functioned properly. The fire extinguishers appeared fully charged and were last serviced on 4/11/2024. The Ventura County Fire Department conducts annual inspections at the facility and will be inspecting the facility tomorrow, 9/20/2024. The facility also has annual inspections of the smoke alarm system conducted by FFS Tech; the last inspection was conducted December 2023. The facility has two generators for use in an emergency which are maintained by the maintenance director. BEDROOMS: There are 37 total bedrooms for resident use – twenty-one (21) are private bedrooms and sixteen (16) room are shared. LPA inspected all occupied (14) resident rooms. Bedrooms were properly furnished with clean bedding and sufficient lighting. Housekeeping cleans the rooms daily. RESTROOMS: There are eleven (11) total bathrooms at the facility for resident use. One (1) is designated as a staff bathroom. The resident bathrooms have roll-in showers with non-skid surfaces and grab bars. The hot water temperature was tested in the bathrooms and ranged from 112.2F - 119.2F which is within the required range of 105F and 120F. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS CARE SENIOR LIVING	FACILITY NUMBER: 565801979
	VISIT DATE: 09/19/2024

NARRATIVE

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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. Common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. The laundry room was observed locked. The locked outdoor courtyard has a covered area equipped with furniture for resident use. There were no bodies of water observed.

KITCHEN: The door to the kitchen remains locked at all times. Knives are stored in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food was adequate. The emergency water supply was adequate. No poisons, pesticides or toxins were stored in any food storage area or preparation area. Appliances in the kitchen were clean and all appeared functional. Cleaning and laundry supplies are stored in locked rooms or cabinets. No flies or other vermin were observed.

INFECTION CONTROL and DISASTER PLAN: The facility has an approved infection control plan. LPA reviewed the facility's disaster plan which was adequate. LPA reviewed the facility's evacuation drills which are conducted quarterly with all staff. The facility has an adequate supply of Personal
Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient.

RECORD REVIEW: LPA reviewed records for four residents, including medications. The medication room was observed to be locked. The medications reviewed by LPA appeared to be given as prescribed. The resident's records were complete. LPA reviewed the facility personnel roster. All personnel are fingerprint cleared and associated to the facility. LPA reviewed four staff files, including training, which were all complete.

No citations were issued. Exit interview conducted and copy of report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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