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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610256
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:30:33 PM

Document Has Been Signed on 08/03/2022 04:30 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:WELLNEST CARE RCFEFACILITY NUMBER:
197610256
ADMINISTRATOR:RATHI, SHIKHAFACILITY TYPE:
740
ADDRESS:28143 SHELTER COVETELEPHONE:
(419) 973-1111
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 6CENSUS: 6DATE:
08/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Shikha RathiTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at 3:00 PM and met with Administrator Shikha Rathi. This is a change of ownership application from Humble Haven RCFE LLC (197609031) to Wellnest Care RCFE (197610256). LPA conducted an entrance interview with the Administrator. At the time of this visit LPA Duguma observed two (02) additional individuals working in the facility. LPA also observed and assessed six (06) residents present in the facility. All residents appear to be clean and well groomed.

With the assistance of the Administrator, LPA conducted a facility tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a single-story property. There is one entrance being utilized at the facility, there are required posters at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has enough PPE supplies. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility was previously fire clearance for six (06) ambulatory of which five (05) may be non-ambulatory and one (01) may be bedridden. Room #4 bedridden room, Room #3 two (02) non-ambulatory, Room #2 one (01) non-ambulatory, Room#1 one (01) non-ambulatory. Approved hospice waiver for six (06). The facility is currently occupying six (06) non-ambulatory residents of which (02) are on hospice care. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water with the required fencing/gating and locking mechanism. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away. LPA inspected the kitchen and observed stove and refrigerator to be clean and working.

(CONT. on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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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: WELLNEST CARE RCFE
FACILITY NUMBER: 197610256
VISIT DATE: 08/03/2022
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Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Trash bin has the appropriate lid. Knives and sharps are observed to be locked and inaccessible to residents. Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen, observed to be full and last inspected on 09/23/2021. The LPA observed entertainment equipment and games for activities. The residents' rooms are adequately furnished with appropriate bedding and lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 112.1°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. No firearms observed.

At the time of this visit, the physical plant meets all Title 22 requirements. Component III orientation completed. No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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