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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320009
Report Date: 04/25/2022
Date Signed: 04/26/2022 10:00:21 AM

Document Has Been Signed on 04/26/2022 10:00 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WELLNESS WORLD LLCFACILITY NUMBER:
198320009
ADMINISTRATOR:GOMEZ, ELIZABETH CFACILITY TYPE:
740
ADDRESS:1119 E 215TH PLTELEPHONE:
(213) 568-7298
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Elizabeth GomezTIME COMPLETED:
04:35 PM
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On 4/25/22, at 2:58 pm, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was allowed entry into the facility by Elizabeth Gomez, Administrator. LPA met with Ms. Gomez and explained the purpose of the visit. The facility is licensed to operate age range 60 and over, of which six (6) maybe non-ambulatory, one(1) maybe bedridden, and hospice waiver for 3. Currently, the facility has 6 residents that include: (4) non-ambulatory, (2) ambulatory, and 3 hospice.

The facility is a two-story residential home located in a residential neighborhood. The facility is located on the first floor, and consist of (3) resident bedrooms, (2) bathrooms, living room, dining room, kitchen, activity room, garage/ storage and backyard with patio cover and tables and chairs. LPA toured the physical plant with Ms Gomez.

There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 105.4 degrees Fahrenheit. A comfortable temperature of 73 degrees was maintained in the facility. The LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and observed to be maintained properly. First Aid kit was checked and has required items. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. Fire Drills were observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WELLNESS WORLD LLC
FACILITY NUMBER: 198320009
VISIT DATE: 04/25/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of the report was provided to Elizabeth Gomez.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
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