197610374-4-10-2024-31-AS-NRED-D47RZX-20240410132840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610374
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:29:04 PM

Document Has Been Signed on 04/10/2024 01:29 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WELL SENIOR CARE		FACILITY NUMBER:	197610374
ADMINISTRATOR/ DIRECTOR:	ERITSIAN, ARMINE AMY		FACILITY TYPE:	740
ADDRESS:	4969 CHIMINEAS AVE		TELEPHONE:	(818) 599-3366
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY: 5		CENSUS: 3	DATE:	04/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Amy Eritsian		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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At 9:20 a.m. on 04/10/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

The facility was last visited on 05/17/2023 for a prelicensing inspection. It is a single story building with three (03) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for five (05) residents, of which five (05) may be non-ambulatory and one (01) of those may be bedridden. The facility serves residents with dementia. Surveillance cameras are used in the common area. Approved hospice waivers for five (05).

LPA conducted resident and interviews at 9:30 a.m. LPA and administrator toured the facility at 10:15 a.m.

At the main entrance, LPA observed postings for confidential complaint contacts, emergency disaster plan, emergency contacts, Ombudsman contacts, house rules, visiting hours, personal rights, rights of resident councils, staff list, resident list, facility sketch with evacuation routes clearly labelled, facility license, and the theft and loss policy. The front entrance also had a sign in sheet and hand sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. Extra linens were located in a storage area near Bedroom #2. At 10:30 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. Two (02) residents were observed watching television in the common area. One (01) resident was observed walking outside with staff.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer and pantry. The stove hood was clean. Appliances were in good condition. At 10:40 a.m. LPA measured the refrigerator temperature to be forty (40) degrees Fahrenheit. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications and complete first aid kit were locked near the refrigerator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELL SENIOR CARE	FACILITY NUMBER: 197610374
	VISIT DATE: 04/10/2024

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LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. Ramps leading up to the main entrance, out the back door, and to Bedroom #3 were stable.

A washing machine and dryer were located in the locked garage. Both were in working order. Detergents were located by the appliances. Extra incontinence and hygiene supplies were also in the garage. All emergency exit paths were free from obstructions. One (01) exit gate was unlocked with an inward facing, self-closing latch. Five (05) out of five (05) auditory alarms were turned on and functioning. At approximately 11:00 a.m. the dual-functioning smoke and carbon monoxide detector was tested and operational. At approximately 11:05 a.m. LPA observed a fully charged fire extinguisher near the office area.

The facility has three (03) bedrooms. All bedrooms contained a lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Chairs were located in the living room based on resident preference.

The facility has three (03) bathrooms. Two (02) bathrooms are private, and one (01) is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight-fitting lid. The shared bathroom and the private bathroom in Bedroom #2 contained grab bars and non-skid mats in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 110.3 degrees Fahrenheit.

LPA conducted a record review of resident and personnel files at approximately 12:00 p.m.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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