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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610500
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:21:32 PM

Document Has Been Signed on 02/01/2024 03:21 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:A WELLNEST CARE RCFE IIFACILITY NUMBER:
197610500
ADMINISTRATOR:RATHI, SHIKHAFACILITY TYPE:
740
ADDRESS:23347 DALBEY DRIVETELEPHONE:
(419) 973-1111
CITY:SANTA CLARITASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 0DATE:
02/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Shikah Rathi, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at around 10:00 AM and met with the Licensee, Shikah Rathi. LPA conducted an entrance interview with the Licensee. LPA Duguma also observed that there were no residents during the inspection. All residents appear to be clean and groomed.
With the assistance of the Licensee, LPA conducted a facility tour of both the inside and outside. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which three (03) may be bedridden and a hospice waiver for one (01). Facility has five (05) bedrooms and two (02) full bathrooms. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. All residents’ bedrooms were adequately furnished. Resident bathrooms have properly installed grab bars and shower has non-skid mats. The average hot water temperature measured at 114.8ºF during the visit.
The common areas were appropriately furnished. The LPA observed entertainment equipment, reading material and games for activities. The has a designated storage cabinet for residents and staff records located near the kitchen and dining area. The first-aid kit is complete. The facility has adequate linen, water, and emergency kits. The linens were stored in the storage space located in the hallway.
(CONT. on LIC809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A WELLNEST CARE RCFE II
FACILITY NUMBER: 197610500
VISIT DATE: 02/01/2024
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LPA observed a fireplace that has appropriate screen. The facility has working egress alarms on all exits. Smoke detectors and Carbon Monoxide detectors were checked and function properly. There are fully charged fire extinguishers located in the kitchen area and hallway. Receipt shows that fire extinguishers were purchased on 10/26/2023 and LPA advised the Licensee to retain the receipt of the fire extinguisher identifying the purchase date to ensure the time frame for annual inspection.

LPA Duguma observed a washer and dryer in the laundry room adjacent to the garage with locking mechanism. All chemicals, additional personal hygiene items will be stored in the locked laundry room. The medications will be stored in a locked cabinet located near the kitchen and dining area.

LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen cabinet.

There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

At the time of this visit the physical plant is meeting Title 22 requirements.

Component III was completed with the LPA.

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: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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