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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610094
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:05:31 PM

Document Has Been Signed on 12/21/2022 12:05 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WELLNESS ASSISTED LIVINGFACILITY NUMBER:
197610094
ADMINISTRATOR:MELIKSETYAN, LUSINEFACILITY TYPE:
740
ADDRESS:9115 N WYSTONE AVETELEPHONE:
(747) 218-9141
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Tamara Ter GrigoryanTIME COMPLETED:
12:15 PM
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On 12/21/2022 at 9:43 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by caregiver Tamara Ter Grigoryan who was wearing a mask and granted access. LPA asked Tamara to call administrator Lusine Meliksetyan but due to a language barrier Tamara did not understand what the LPA was requesting LPA called administrator Lusine and explained the reason for the visit. Lusine told LPA she will not be meeting us at the facility because she was in another city. Administrator designated caregiver Tamara Ter Grigoryan to sign for this report. LPA reviewed the Mitigation Plan approved 03/04/2021. The inspection tool was used to complete the visit.

At 9:53 a.m. LPA and caregiver Tamara began a physical plant tour of the facility and the following was observed:

Infection Control: Infection Control: LPA observed appropriate infection control signs posted in front of the door. Upon entry staff was wearing a mask. LPA observed appropriate infection control signs posted along the entry. Hand sanitizer, gloves and masks were observed available for use. Tamara took LPA's temperature and requested LPA to sign in. Tamara states the facility has enough PPE for 30 days. Kitchen: At 9:58 LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed a 2-day perishable and 7-day non-perishable supply of food. LPA observed caregiver preparing breakfast for residents. LPA observed a table with bar stool chairs by the kitchen that were clean and in good repair. Fire extinguisher by kitchen was fully charged and purchased 09/26/2022. Common Area: Common areas include one sitting area, one tv area and a dining area. All areas were well lit, clean and clear of clutter. Furniture was clean and in good repair. A fireplace in the dining area was adequately screened. Appropriate infection control signs were posted along a wall in the tv/dining area. (Continue on 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
VISIT DATE: 12/21/2022
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Office area: Includes a desk with chair and a small couch. Area was clean an clear of clutter. LPA observed resident files and medications are stored in the office area. Medication is kept locked in a filing cabinet inaccessible to residents in care. Resident files and staff files are kept in a cabinet in the office desk. During the physical plant tour at 10:22 a.m. LPA observed the staff bathroom by the entry was unlocked. Inside the cabinet LPA observed cleaning chemicals. Tamara removed the cleaning chemicals immediately and pointed to the sign on the door that read employee only. LPA explained to Tamara that this bathroom is accessible to residents because it does not lock on the outside. LPA continued the tour to the laundry room that leads to the garage. Door to the laundry room is kept locked. Inside the laundry room was a washer and dryer that appeared functional. In the hallway LPA observed thermostat at a comfortable 74 degrees Fahrenheit. LPA observed additional bedding and linens sufficient for all of the residents in hallway closet. Resident Rooms: Facility has four (4) bedrooms of which one is a shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which one is designated for staff and visitor’s use and another is in a residents private room. LPA observed all bathrooms to be clean. Grab bars and non-skid mats were observed. LPA asked Tamara who uses this shower she stated, only one (1) out of five (5) residents use this shower. LPA observed hand washing signs and sufficient amount of hand soup and paper towels. The hot water was tested and measured 117.1 degrees Fahrenheit, which is in regulation. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate was observed closed but unlocked. There is appropriate outdoor seating with shade for residents. LPA observed a water fountain not in use but with sitting water surrounded by a gate making it inaccessible to residents. LPA observed smoke alarms through out the facility that are interconnected and dual carbon monoxide. At 11:20 a.m. all smoke/carbon monoxide detectors were tested and functioned properly.

Deficiency cited (refer to 809D). Exit inter conducted. Appeal rights provided. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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Document Has Been Signed on 12/21/2022 12:05 PM - It Cannot Be Edited


Created By: Evelin Rios On 12/21/2022 at 11:46 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)

87705(f) The following shall be stored inaccessible to residents...(1) Knives, matches, firearms...(2) Over-the-counter medication... cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one (1) out of 3 (three) facility bathrooms having cleaning chemicals under an unlocked sink cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
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Caregiver removed cleaning chemicals immediately. No POC required at this time.
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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022


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