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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801979
Report Date: 04/26/2023
Date Signed: 04/26/2023 06:59:48 PM


Document Has Been Signed on 04/26/2023 06:59 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: 25DATE:
04/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Maria HernandezTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit to the above facility. LPA met with Administrator Maria Hernandez at 9:30 a.m..

During a file review on 04/11/2023 and 04/26/2023, LPA Ascencio observed discharged documents for Resident #1 ( R1) because of a fall, dated 12/06/2021. Additionally, LPA Ascencio observed a shift communication log entry indicating R1 was picked up by a staff member at the hospital on 12/06/2021. The documents observed confirmed R1 had a fall on 12/06/2021.

LPA Ascencio conducted interviews with Staff #1 (S1) on 12/22/2021, Administrator Hernandez on 04/11/2023 and R1’s family member on 04/25/2023 all who confirmed R1 having a fall on 12/06/2021. LPA Ascencio requested a copy of the incident report for R1’s fall. Administrator Hernandez could not find a physical or digital copy. LPA Ascencio observed the Department’s incident report database and could not find an incident report for R1.

1 citation was observed during today’s visit.


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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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Document Has Been Signed on 04/26/2023 06:59 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: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

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87211(a)(1)(b) Reporting Requirements A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events…Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:
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Administrator will submit an incident report for R1's fall in 12/6/2021. Administrator will conduct all staff training on section 87211 and will submit copied of material and send to CCL by 5/12/2023.
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Based on interviews and file review, the licensee did not comply with the section above as R1’s was sent to the hospital on 12/6/2023 and no written notification to CCL was given which poses a potential health, safety or personal rights 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: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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