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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610731
Report Date: 03/25/2026
Date Signed: 03/25/2026 03:00:15 PM

Document Has Been Signed on 03/25/2026 03:00 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WELLCARE HOMEFACILITY NUMBER:
197610731
ADMINISTRATOR/
DIRECTOR:		OHANYAN,ARUSYAKFACILITY TYPE:
740
ADDRESS:3133 DONA SARITA PLTELEPHONE:
(818) 424-2217
CITY:STUDIO CITYSTATE: CAZIP CODE:
91604
CAPACITY: 6CENSUS: 6DATE:
03/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Chris RaigTIME VISIT/
INSPECTION COMPLETED:
03:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff,Irene Lantang and Chris Raig, and explained the reason for the visit. Staff does not have background clearance, Immediate Civil Penalty (LIC 421CG) will be issued. Approximately, around 9:55 AM new licensee, Tigran Gevorgyan, arrived and was explained for the reason of the visit. New licensee is not associated with the above facility and an application was receive from Centralized Application Bureau (CAB) for Change of Ownership (CHOW) on 8.11.2025.

At 10:00 AM, with the assistance of new licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 10:58 AM smoke alarms were tested and are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is located in the kitchen with a charge date of 7.16.2025. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) residents six (6) non-ambulatory resident, of which one (1) maybe bedridden, cleared for bedroom #2; hospice waiver for five (5).

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen.

Bedrooms: There were three (3) bedrooms designated for residents' use. Bedroom #1, bedroom #2, and bedroom #3 are shared and is used for residents only, Bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2026
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 16
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 16
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WELLCARE HOME
FACILITY NUMBER: 197610731
VISIT DATE: 03/25/2026
NARRATIVE
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Bathrooms: The facility has two and a half (2.5) bathrooms. Bathroom #0.5 is located by the living room by the facility entrance. Hot water measured at 105.4 degrees Fahrenheit. Bathroom #1 is located by the hallway beside bedroom #1. Hot water measured at 106.1 degrees Fahrenheit. Bathroom #2 is located inside bedroom #2. Hot water measured at 113.5 degrees Fahrenheit. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Residents dining table fits enough for six (6). In the kitchen area LPA observe a sofa for staff to rest and take a break. LPA also observe that the sofa is a sofa bed where staff stated that they sleep in. Deficiency will be cited on LIC 9099-D.

Surrounding Grounds: Entry and exits were free of obstruction. The furniture were observe to be appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a garage and is use for storage and laundry. Detergents and cleaning supplies are being stored in the locked garage. The facility does have a swimming pool and was observe by the LPA to be unlocked. Deficiency will be cited in LIC 9099-D. Office space is beside the entrance of the facility. Properly labeled medications were locked in the kitchen cabinets. LPA observe medications were prep in a plastic ramekin and was accessible and unlock on the kitchen counter-top beside the microwave. Deficiency will be cited in LIC 9099-D.

Resident Files: LPA was not able to conduct a file review of resident records to ensure compliance of licensing forms. No files are available for LPA. Deficiency will be cited in LIC 9099-D.

Staff Files: LPA was not able to conduct a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Deficiency will be cited in LIC 9099-D.

Medications: No Medication and Medication Records (MMR) were able for LPA to review for proper documentation. Deficiency will be cited in LIC 9099-D.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were observed during the visit.

Exit interview conducted and a copy of the report issued.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:34 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type A
Section Cited
HSC
1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, licensee did not comply with the section cited above in 1 out of 1 all staff does not have CPR which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
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All facility staff needs CPR training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 4 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:35 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(C)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 no infection control documents were provided to LPA, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee will provide LPA infection control to review.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 facility does not have liability insurance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee will provide liability insurance to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 5 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:35 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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 1 out of 1, staff revealed they sleep in the kitchen area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee will send a new facility sketch and provide a divider for staff space (bed).
Type B
Section Cited
CCR
87468(b)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interrview, the licensee did not comply with the section cited above in 1 out of 1 all of the 6 residents does not have admission agreement for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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4
Licensee will provide admission agreement file for LPA to review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 6 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:35 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1, licensee stated that they do not have first aid kit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee will purchase a first aid kit.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 1 out of 1 all residents medication were observe to be accessible in the kitchen counter top that was transferred from its orginal container to a plastic ramekin, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee and staff understood that moving forward no more transfer of medication to another container.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 7 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:36 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 1 out of 1, licensee could not provide CSMDR of residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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2
3
4
CSMDR needs to be provided to LPA for review.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 1 out of 1, licensee did not provide any records for LPA to review, facility file, staff file, and residents file needs to be accessible for LPA to review. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure files are ready for LPA to review by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 8 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:36 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)(A)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 1 out of 1, no residents records are available for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1, all of residents Physician report was not available, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 9 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:36 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1, all residents records were not avaialble for LPA check for TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure all residents has a TB test in their physician report (LIC 602).
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1, licensee did not provided ambulatory status of all the 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


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Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:37 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, no residents records are avaible for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


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Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:37 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, no residents records are avaible for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


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Page: 12 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:37 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, no admission agreement was avialble for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.
Type B
Section Cited
CCR
87508(b)
Register of Residents
(b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Registers may be removed if necessary for copying. Removal of registers shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, no records are avaible for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure facility file are availe in the facility for LPA to review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:37 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, no records are avaible for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure facility file are availe in the facility for LPA to review.
Type B
Section Cited
CCR
87608(a)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, no residents records are avaible for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
Licensee will ensure residents file are availe in the facility for LPA to review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 01:46 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)(2)(A)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out 1, pool fence lock was observe to be unlock, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
1
2
3
4
Licensee/ staff lock the pool fence.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 15 of 16
Document Has Been Signed on 03/25/2026 03:00 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 03/25/2026 at 02:38 PM
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: WELLCARE HOME
FACILITY NUMBER: 197610731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1, 2 staff and licensee are not fingerprint cleared to be working at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
1
2
3
4
Licensee and staff needs to get fingerprint cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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