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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609565
Report Date: 11/30/2021
Date Signed: 12/02/2021 04:50:15 PM

Document Has Been Signed on 12/02/2021 04:50 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WHOLESOME LIFE SENIOR LIVINGFACILITY NUMBER:
197609565
ADMINISTRATOR:TASHCHYAN, ARPINEFACILITY TYPE:
740
ADDRESS:22040 COVELLO STTELEPHONE:
(310) 975-5452
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Jerry TeoderoTIME COMPLETED:
04:20 PM
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On 11/30/2021 at 2:51 PM, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit to Wholesome Life Senior Living. LPA met with Staff and disclosed the reason for the visit. LPA conducted the visit under the Infection Control Domain of Licensing’s Compliance and Regulatory Enforcement (CARE) Tools.

The census of residents was 4.

At approximately 3:11 PM, LPA conducted facility tour inside and out

At approximately 3:47 PM, LPA and staff reviewed CARE tool.

Due to time constraints, LPA did not finish the report. LPA will return 12/02/2021 to complete report.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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