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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609336
Report Date: 09/19/2025
Date Signed: 09/19/2025 01:53:10 PM

Document Has Been Signed on 09/19/2025 01:53 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WELBROOK SENIOR LIVING SANTA MONICAFACILITY NUMBER:
197609336
ADMINISTRATOR/
DIRECTOR:		COLE, CATALINAFACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 50CENSUS: 49DATE:
09/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Catalina Cole-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 09/19/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conducted a annual inspection. Upon arrival LPA met with the Wellness Director- Chhandita Panday who was informed of the purpose of today’s visit. Administrator Catalina Cole arrived at 9:00 AM and she was also informed of the purpose of todays visit.

The facility is licensed to care for (50) non-ambulatory residents ages 60 and over and approved for(15) hospice waivers. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (50) resident bedrooms, (50) resident bathrooms and (4) public restrooms, dining room, laundry room, business offices,kitchen,outdoor patio,salon,medication room,and an employee lounge. The facility temperature ranged from 73 - 79 degrees F.

At 9:00AM, LPA Allen and Catalina toured the physical plant. There were no bodies of water on the premises.

At 9:15AM, LPA Allen and Catalina inspected bedrooms #101, #110, #216, #218 and #232 the bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F.
The bedrooms have the required furniture such as beds and bedding supplies which appeared to be in good condition,there is adequate lighting provided, and storage for the resident's personal belongings

Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to residents.

Continued....
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 09/19/2025
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The kitchen was inspected, and there was a 5-day supply of perishable and a 7-day supply of non-perishable food items available, which were adequately maintained and stored there was also a menu available for review.

The fire extinguishers, carbon monoxide detectors and smoke detectors were fully charged and operable. The last fire drill was 9/2/2025.

At 11:45 AM, LPA Allen reviewed four (4) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be up to date.


LPA Allen reviewed four (4) staff files to verify First Aid/CPR certification, criminal record clearance, and health screenings. All reviewed items appeared to be current and up to date. However, during the review of staff files for S1, S2, S3, and S4, no annual training records were available for review and not in compliance with Title 22, Division 6, Chapter 8.

Based on the observations made during today’s visit, a deficiency was cited.

An exit interview was conducted where this report LIC809, 809-C and LIC809D was discussed and provided to Catalina Cole- Administrator at the conclusion of the visit with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2025 01:53 PM - It Cannot Be Edited


Created By: Bernadette Allen On 09/19/2025 at 12:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1-6)

Personnel Requirements 87411 (c) (1-6) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 .
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interviews,and record review, the licensee did not comply with the section cited above in 4 out of 4 staff members did not have proof of trainings in their file for S1,S2,S3,and S4, nor could the administration staff provide proof of trainings for any staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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The Adminstrator Catalina Cole has agreed to provide training to all support staff members and provided proof of training signed and dated by staff members along with a statement of understanding of the cited regulation by the POC date of 9/26/2025 by email to Bernadette.allen@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Bernadette Allen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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