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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801979
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:55:29 PM


Document Has Been Signed on 10/02/2024 04:55 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 LIVINGFACILITY NUMBER:
565801979
ADMINISTRATOR:MARIA HERNANDEZFACILITY TYPE:
740
ADDRESS:158 ROCKAWAY ROADTELEPHONE:
(805) 649-5143
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:56CENSUS: 18DATE:
10/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Maria HernandezTIME COMPLETED:
01:00 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 a case management - deficiencies visit due to a deficiency observed during the course of a complaint investigation (complaint control number 29-AS-20240926092818). LPA initially met with the medication technician staff 1 (S1) who called the administrator. The administrator Maria Hernandez arrived at 11:24 a.m.

LPA interviewed four staff starting at 10:52 a.m. and the administrator starting at 11:24 a.m. Three staff confirmed that the facility van is working but not able to be used due to lack of insurance and the registration is not current. LPA confirmed this with the administrator. This van is normally used to take residents to appointments and activities or scenic drives. At 11:47 a.m. LPA observed the van is currently being used to store personal property and has expired tags (expired June 2024).

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited
(refer to LIC 809-D).
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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 2


Document Has Been Signed on 10/02/2024 04:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2024
Section Cited
CCR
87312

1
2
3
4
5
6
7
87312 Motor Vehicles Used in Transporting Residents. Only drivers licensed for the type of vehicle operated shall be permitted to transport residents... Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee will provide proof of insurance and proof of registration payment for the facility van to CCL on or before 10/16/2024.
8
9
10
11
12
13
14
Based on interviews and observation, the licensee did not comply with the section above as the registration and insurance has not been maintained for the facility van, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2