BE WELL SENIOR LIVING INC.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on interviews and observations the Licensee did not comply with the above cited section in the facility’s fire safety was not maintained which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will submit an updated LIC 200 and facility sketch, and contact LAFD City for an updated fire clearance and consultation. Proof will be provided to CCLD by POC due date.

Deadline recorded: Jun 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above in 1 out of 2 carbon monoxide detectors were inoperable which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will obtain a combination smoke and carbon monoxide detector and provide proof by POC due date.

Deadline recorded: Jun 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 carbon monoxide detectors were inoperable which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/25/2026 Plan of Correction Staff replaced the batteries during the visit. The Licensee will review regulations and submit a statement of understanding to CCLD by POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in hot water was not within the required range which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/25/2026 Plan of Correction The Licensee will adjust the water temperature, measure each resident sink, and submit proof to CCLD by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in staff did not recieve required training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction The Licensee will inquire a third party training platform and provide all staff with the required training and send proof to CCLD by POC due date.

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in staff did not recieve required training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction The Licensee will inquire a third party training platform and provide all staff with the required training and send proof to CCLD by POC due date.

Official classification

Type B

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 2 residents did not have an updated medial assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2026 Plan of Correction The Licensee will obtain updated medical assessments and provide it to CCLD by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in residents did not have an updated and signed appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2026 Plan of Correction The Licensee will provide CCLD with updated and completed appraisals by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in the facility did not conduct emergency drills as required which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2026 Plan of Correction The Licensee will provide CCLD with emergency drill documentation by POC due date.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 resident had full bed rails and is not on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2026 Plan of Correction The Licensee will change R1's full bed rail to a half bed rail and send proof to CCLD by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

HSC

What the official deficiency says

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: At 9:22AM LPAs and IB Investigator toured the facility and observed centrally stored medications in the refrigerator to be accessible and not locked. Addiitonally, R1 stores self administered medication in their room that does not have a lock on the door.

Official plan of correction

Licensee will install a lock on R1's bedroom door and send proof of both corrections to CCL by POC Date. Licensee corrected refrigerator medication box during the visit.

Deadline recorded: Apr 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as residents stated staff sleep at night and are not available to assist when residents with their care needs, which poses a potential health and personal rights risk to persons in care.

Official plan of correction

Administrator agreed to retrain night staff on facility policies and procedures related to call response times and appropriate break times. Proof of staff training will be provided to CCL by POC due date.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as the facility bathroom was observed with mold and broken toilet parts, a broken lock in the kitchen, and dirty/dusty vents throughout the facility, which poses a potential health risk to residents in care.

Official plan of correction

Administrator agreed to clean the identified areas of the faciilty and to fix both broken items. Proof of correction (photographs) will be sent to CCL by POC due date.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in two (2) out of seven (7) bathrooms had water temperature above120 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction At the time of the visit the Administrator was able to adjust the water temperature and get it to the required range of 105–120- degree Fahrenheit with a temperature of 114.4 at 3:18pm. Licensee agrees to keep a water log for the bathrooms of the home. Begin the water log today 03/11/25 through 03/18/25 and send a copy of the completed water log to LPA by 03/21/2025.