Be Well Senior Living

Allegation investigated: Facility in violation of Fire Safety

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced initial complaint visit for the above allegation. The LPA arrived at 3:24PM and met with Staff Felisa Lacsamana. The Licensee Ruslan Melnikov arrived at 4:35PM. Entrance interview conducted. Between 3:30PM and 4:10PM, the LPA and Staff conducted a physical plant tour and tested the facility’s carbon monoxide and smoke detectors. The following was then determined: Allegation: “Facility in violation of Fire Safety” Report Continued on LIC 9099-C Substantiated It was reported that the facility did not have a functioning fire extinguisher, smoke detectors, or required fire doors. Today’s visit revealed that there was one (1) fire extinguisher on the premises that was fully charged and last serviced on 01/27/2026. Smoke detectors were tested and were not hardwired, with only two (2) out of eight (8) detectors functioning and testable. One (1) operational smoke detector was located in the middle of the facility, above the kitchen, and the other was in a resident’s room located at the front of the facility. Two (2) carbon monoxide detectors were tested and one (1) was operational. A double door located in the middle of the facility was observed as well as each resident bedroom door, and the facility did not have required fire doors. The Licensee stated that upon approval of licensure, fire doors were not required, and the facility has not made any changes that would require fire doors. The LPA consulted with a Los Angeles Fire Department (LAFD) City Fire Inspector who confirmed that the facility required fire doors and hardwired smoke detectors due to the facility’s approved resident status. The facility was approved for five (5) non-ambulatory and one (1) bedridden, for a total of six (6) residents. Based on interviews and observations, the preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. An immediate civil penalty in the amount of $500 was assessed for a violation of the facility’s fire clearance (Refer to LIC 421M). The Licensee was advised that failure to correct may result in additional civil penalties. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 29-AS-20260617112035

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 18, 2026

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.the state’s words, verbatim · CDSS document, Jun 17, 2026

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.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20260617112035. The LPA arrived at 3:24PM and met with Staff Felisa Lacsamana. The Licensee Ruslan Melnikov arrived at 4:35PM. Entrance interview conducted. Between 3:30PM and 4:10PM, the LPA and Staff conducted a physical plant tour and tested the facility’s carbon monoxide and smoke detectors. One (1) out of two (2) carbon monoxide detectors were non-operational as Staff had removed the battery. On 02/24/2026, the facility was cited the same deficiency where staff removed the battery due to the constant beeping. The Administrator Elina Root and Licensee stated that the alarm above the kitchen was a combination smoke and carbon monoxide detector, however the LPA’s inspection of the detector and google search of the equipment revealed that it was a smoke alarm. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to 809-D). A civil penalty in the amount of $250 was assessed for a repeat violation within a twelve (12) month period (Refer to LIC 421FC). The Licensee was advised that failure to correct may result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.311 · Plan of correction due date: Jun 18, 2026

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.the state’s words, verbatim · CDSS document, Jun 17, 2026

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:35AM. The LPA met with Staff and informed them of the reason for the visit. The Administrator Ruslan Melnikov arrived at 11:44AM. Entrance interview conducted. Beginning at 10:46AM, the LPA and Staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. Required postings were observed in the entryway. The facility maintained a comfortable temperature throughout the visit and nightlights were observed throughout the hallways. KITCHEN: The LPA observed knives and cleaning supplies stored inaccessible. Kitchen appliances were clean and in operable condition. Food in the refrigerator and freezer were observed to be properly stored and of good quality. The facility had a sufficient supply of perishable and non-perishable food. Non-perishables and emergency food and water were stored in a nearby pantry. Report Continued on LIC 809-C BEDROOMS/RESTROOMS: There were seven (7) total bedrooms: six (6) private resident rooms and one (1) locked staff room. Bedrooms #1, #2, and #3 had a direct exit to the outside and the facility approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in each residents’ room. There were seven (7) total restrooms in the facility: six (6) private and one (1) shared. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 112.1 degrees F and 124.5 degrees F, which is not within the required range. OUTDOOR AREA: The rear yard had shaded patio areas equipped with furniture in good condition for resident and visitor use. Exits and passageways were free of obstruction. There were two (2) emergency side exits with a self-latching gate. The facility had a secured garage that contained general storage with operational laundry machines behind the garage. RECORDS: Record review began at 11:21AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Two (2) residents did not have Physician’s Reports updated, one (1) resident did not have an Appraisal updated annually as required, and one (1) resident’s Appraisal was not signed nor dated. Resident #1 (R1) was observed to have full bed rails and was not on hospice. On 04/18/2025, a Complaint and Case Management visit was conducted, and the full bed rails were addressed with the Administrator. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The Administrator provided the LPA with staff training between 11/01/2024 to 11/10/2024 and then provided the LPA with exact copies of the 2024 training with the dates whited out and changed to 2025. The Administrator then stated it was a mistake and that the updated staff training was with the second Administrator who was unavailable. The Administrator stated that they conduct the training that comes in the form of videos and discussions. Report Continued on LIC 809-C The LPA spoke with two (2) out of two (2) staff who confirmed they only received training in 11/2025 regarding emergency disaster and how to use the fire extinguisher, which was done within one (1) day. No additional training topics or hours were completed. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Fire extinguishers were observed and last serviced on 01/27/2026. No records of emergency disaster drills were observed or provided during the visit. Smoke and carbon monoxide detectors were tested at 1:25PM. Smoke detectors were operational and one (1) out of two (2) carbon monoxide detectors were missing their batteries. Staff stated they removed the battery due to the constant beeping and replaced the batteries during the visit. MEDICATIONS: Medication review began at 1:32PM. Medications were centrally stored and kept inaccessible in a medication closet. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA advised the facility that they could not longer prepare medications in advance. A civil penalty in the amount of $250 was issued for a repeat citation within 12 months (Refer to LIC 421FC). The Administrator was informed that failure to correct may result in additional civil penalties. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 24, 2026

Allegation investigated: Staff do not answer resident's call button in a timely manner Staff do not ensure that the facility is maintained sanitary Staff do not ensure resident's care needs are met

Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh, along with Investigations Branch (IB) Investigator Michele Salant conducted an initial complaint investigation for the allegations listed above. LPAs and Investigator arrived at the facility at 09:16AM and initially met with facility staff. Administrator was contacted via telephone and arrived at 10:17AM. Entrance interview conducted. During today's visit, LPAs toured the facility along with facility staff at 09:22AM, interviewed 3 (three) residents and 4 (four) staff at various times throughout the visit, interviewed Administrator at 10:17AM, reviewed and obtained copies of relevant documents, and conducted a medication review at 12:04PM. The following was then determined: Allegations: "Staff do not respond to call button timely" and "Staff do not ensure resident's care needs are met:" Report Continued on LIC 9099-C Substantiated all medications observed were labeled as required. No discrepancies were observed during the medication review. One resident (Resident #1 - R1) is able to store and administer their own prescription, over the counter and PRN (as needed) medications. Some of R1's medications were centrally stored and others were stored in R1's room. Residents and staff interviewed indicated medications are administered as prescribed. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today's report was provided. The complaint alleges that when residents request assistance, staff do not respond timely. Interviews with residents revealed that particularly during the night, staff do not respond to calls for assistance. Interview with Administrator revealed that the facility has 2 (two) care staff present from 07:00 or 08:00AM until 06:00PM. Between the hours of 06:00PM to 07:00 or 08:00AM, there is 1 (one) awake staff present at the facility. Personnel Report indicates 1 (one) awake staff scheduled from 07:00PM to 07:00AM 7 (seven) days a week. Staff and resident interviews revealed that during the night shift, staff take naps and are therefore not available to assist residents in meeting their needs. Most residents interviewed stated they have bells to use to request staff assistance, while other residents stated they just yell when requesting assistance. Residents reported slipping down from their bed and requesting assistance with medications during the night shift and staff did not respond. Staff interviewed indicated they do try to respond as quickly as possible when residents request assistance, but at times, they are busy assisting another resident and cannot respond timely. Based on interviews, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Allegation: "Facility staff do not ensure facility is maintained sanitary:" During today's visit, LPAs and IB Investigator observed dirty/dusty vents throughout the facility, mold in the grout in the facility's common shower, sticky floor in the shared resident restroom, and dirt and mold were observed in the facility kitchen, both on the floor and around the kitchen sink. Although facility staff interviewed indicated there is a regular cleaning schedule, with cleaning tasks assigned daily, every other day or weekly, LPAs did not observe a cleaning log or any documentation of cleaning tasks completed. Additionally, LPAs and Investigator observed the lock on the knife drawer in the kitchen was broken and unable to be used. There were also broken toilet parts observed in the common facility restroom. Based on observation, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 29-AS-20250417081503

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 2, 2025

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.the state’s words, verbatim · CDSS document, Apr 18, 2025

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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 2, 2025

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.the state’s words, verbatim · CDSS document, Apr 18, 2025

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.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Quoc Huynh and Kelly Dulek along with Investigation Bureau (IB) Investigator Michelle Salant conducted an unannounced visit at the facility in conjunction to an investigation of complaint control # 29-AS-20250417081503. During today's investigation, LPAs, IB Investigator, and Staff toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations at 9:22AM. LPAs and IB Investigator observed centrally stored medicine in the kitchen refrigerator to be located on the fridge door as well as an unlocked box. LPAs and IB Investigator also observed Resident 1 (R1) has self administered medication that R1 stores in their room which does not have a lock on the door. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Apr 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87465(h)(2) · Plan of correction due date: Apr 23, 2025

(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.the state’s words, verbatim · CDSS document, Apr 18, 2025

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.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:30a.m. Upon arrival, LPA Mosley was greeted by staff and called the Administrator to inform them of the visit. The Administrator arrived shortly after. The LPA met with Co- Administrators Elina Root and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. INTERVIEWS: From 10:40 a.m. - 11:00 a.m. One (1) staff and three (3) resident interviews were conducted during the inspection. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. At 1:46 p.m., smoke detector(s) and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 2/21/2025. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 12/1/2024 and conducted quarterly with the next one scheduled this month. Activities were observed in the common areas. An adequate supply of emergency food and water was observed in the pantry adjacent to the kitchen. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. Inside temperature was maintained at a comfortable level. BEDROOMS: The facility is a single-story residential home with seven (7) bedrooms of which six (6) are for resident use and one (1) for staff use. Resident bedrooms are private, single occupancy with its own bathroom. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Staff room remains locked at all time. Report Continued on LIC 809C... Report Continued from LIC 809... BATHROOMS: The facility has a total of seven (7) bathrooms. Six (6) are private resident bathrooms and one (1) is a shared, common bathroom for resident use. Restrooms were clean and sanitary and in operating condition with grab bars and slip resistant surfaces. Hot water was measured in all resident bathrooms from 11:01a.m. - 11:20a.m. and measured between 121.1 - 124.1 degree Fahrenheit over the required range temperature of 105–120 degree Fahrenheit posing an immediate health and safety risk to persons in care. 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. The sinks had sufficient liquid soap, and paper towels. KITCHEN: The LPA inspected the kitchen/food service area at 11:21 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 114.4 degrees Fahrenheit at 11:21 a.m. Cleaning solutions, toxins, chemicals, and hazardous items were inaccessible and locked away inside a kitchen cabinet under the sink. OUTDOOR SPACE/ GARAGE: The LPA observed the back yard which had two (2) portable outdoor umbrellas for shade along with patio furniture including tables and chairs for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There were no bodies of water observed on the premises at the time of the visit. The garage is kept locked and inaccessible to residents. LPA observed an extra refrigerator with extra food that was checked for proper labels and expiration dates. The laundry units were observed outside adjacent to the garage in its own covered area. LPA observed laundry detergent locked, inaccessible to residents stored in the garage. RECORDS: Records review began at 11:30 a.m., six (6) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records in order. At 12:40 p.m. six (6) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Report Continued from LIC 809C... Report Continued from LIC 809... Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate. MEDICATIONS: Medications review began at approximately 1:50 p.m. Medications are centrally stored and locked in a closet adjacent to the kitchen; Medications for five (5) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed. Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, and current Liability Insurance. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at 09:30 a.m. at the facility unannounced to conduct a required annual inspection. LPA Urena was greeted by staff, and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Administrator Elina Root and explained the reason for the visit. LPA Urena and the Administrator conducted a tour of the physical plant inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 04/15/2023. The LPA observed required postings in the hallway by the main entrance door. KITCHEN: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. BEDROOMS: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. BATHROOMS: Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom. Continues on LIC809 C... OUTDOOR/GARAGE: Backyard has an area equipped with outdoor furniture for residents’ use. Shade is provided with patio umbrellas. No bodies of water noted. Side gate is unlocked. The property has a detached garage; the garage door was locked at the time of the visit. The washer and dryer are located behind the garage in an open space. Laundry and cleaning products are kept locked in the garage. RECORDS: Records review began at 11:06 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 12:11 p.m.; medications are centrally stored and locked in a closet adjacent to the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 12, 2024