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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609565
Report Date: 12/02/2021
Date Signed: 12/02/2021 04:48:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/02/2021 04:48 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:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:16 PM
MET WITH:Arpine TashchyanTIME COMPLETED:
04:47 PM
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On 12/02/2021 at 4:16 PM, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit to Wholesome Life Senior Living. LPA met with Administrator and disclosed the reason for the visit.

The census of residents was 4.

Facility has a Mitigation Plan, approved by the Regional Office, to mitigate the spread of COVID-19 in the facility.


At approximately 3:11 PM on 11/30/2021, LPA conducted facility tour inside and out

At approximately 3:47 PM on 11/30/2021, LPA and staff reviewed CARE tool. LPA completed and delivered report on 12/2/2021.

ENTRY: Before entering, LPA saw four signs on the front door requiring social distancing, the use of face masks, as well as certain visitors prohibited. LPA observed one central entry point designated for the screening of all residents, staff, and visitors, and hand sanitizer was available upon entry. Staff screened LPA for symptoms and temperature prior to entering the facility. LPA signed in and recorded temperature on a sign-in log. The screening station also had hand sanitizer for visitor use. LPA saw a symptom screening log (+/- temperature and symptom check) for all staff and residents. Staff monitors resident temperatures twice daily.


TOUR: Once inside, LPA observed signs posted promoting handwashing practices, social distancing, reporting signs and symptoms of COVID, and wearing masks. LPA observed two residents in the common area. Furniture appeared to be clean and in good repair. Seating was arranged to accommodate social distancing for all residents. 1 out of 1 staff and 2 out of 2 residents in the living room wore face coverings. The facility utilizes the living room as a visitation area. The outside patio also offers visitation space. Staff noted the facility, especially high traffic areas, are cleaned twice a day at a minimum.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WHOLESOME LIFE SENIOR LIVING
FACILITY NUMBER: 197609565
VISIT DATE: 12/02/2021
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Bathrooms: LPA observed 3 out of 3 bathrooms with functional sinks, fully stocked liquid soap, trash cans with tight fitting lids and signs directing proper handwashing technique. 1 out of 3 bathrooms contained a personal hand towel for drying, while paper towels were available outside of the restrooms. Staff provides paper towels with each restroom use for safety reasons.

Bedrooms: LPA observed 6 private bedrooms, all of which were clean and in good repair. All windows were clean with functioning blinds and screens. One bedroom was vacant.

Outside: LPA observed adequate amounts of gowns, N95 masks, incontinence supplies, and sanitizer in outdoor storage area. LPA also observed masks and gloves in staff room. The outdoor area was clean and free of debris.



Staff informed LPA all residents have been notified about facility infection control policies. Staff also noted the facility has procedures for when to test staff and residents to monitor the spread of the virus and mitigate outbreaks, and the facility tests staff during hiring process and residents before admission for COVID-19. Staff showed LPA a vacant room which can be used for isolation purposes. Staff stated they are knowledgeable of proper PPE donning and doffing, and they are able to serve meals and medication if residents undergo isolation. Facility is able to serve all meals and deliver medications to residents in isolation, and the Facility developed a plan to ensure appropriate cleaning of isolation rooms.

Exit interview conducted. Report emailed to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
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