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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801979
Report Date: 05/12/2022
Date Signed: 05/12/2022 08:30:58 PM


Document Has Been Signed on 05/12/2022 08:30 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, 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:
05/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Maria HernandezTIME COMPLETED:
05:50 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 Analysts (LPAs) JoAnn Rosales and KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection at the facility today.

During the inspection, record review revealed two staff members, Staff #1 (S1) and Staff #2 (S2) have criminal record clearance but their criminal clearance records have not been transferred to the facility. Records indicate both staff have worked at the facility in excess of five days. This is an immediate civil penalty and civil penalties will be assessed in the amount of $100 per day for five days ($100 x 5 days) for both S1 and S2.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations and/or Health and Safety Code, the following deficiency was cited and civil penalty issued in amount of $500 and $500. (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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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 05/12/2022 08:30 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
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: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/12/2022
Section Cited

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing.. in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agrees that S1 & S2 will not work at the facility until their criminal record clearance has been transferred to the facility. Plan of correction cleared.
Civil penalties are being assessed in the amount of $1000 ($500x2). See LIC421BG.
8
9
10
11
12
13
14
Based on record review, the licensee failed to comply with the section cited above as two staffs' (S1 & S2) criminal record clearance were not transferred to the facility which poses an immediate health and safety risk to residents 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) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2