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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320692
Report Date: 09/11/2026
Date Signed: 09/11/2026 03:19:40 PM

Document Has Been Signed on 09/11/2026 03:19 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WELBROOK SANTA MONICAFACILITY NUMBER:
198320692
ADMINISTRATOR/
DIRECTOR:		COLE, DAVID C.FACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 50CENSUS: 46DATE:
09/11/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:David ColeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to CCLD for a Change of Ownership for a Residential Care Facility for the Elderly to serve residents age range 60 and over. The facility is approved for fifty (50) non-ambulatory residents of which fifteen (15) may be bedridden in any rooms on the first floor. The facility has a hospice waiver for fifteen residents with total care. It currently has one bedridden resident and eight residents receiving hospice services.

Structure:
The facility consists of two floors with fifteen (15) bedrooms on the first floor and thirty-five (35) bedrooms on the second floor. There is an outdoor patio area near the dining room. The facility has multiple offices and storage rooms, three activity areas, two medication rooms, a salon, dining room, kitchen, laundry room, break room, janitor closets, mechanical room, and utility room. The community is clean, sanitary, and in good repair. Indoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions and well-lit.
Ulysses Coronel
Regina Cloyd
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELBROOK SANTA MONICA
FACILITY NUMBER: 198320692
VISIT DATE: 09/11/2026
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All window screens are clean and in good repair.
Physical Plant:
Seven (7) bedrooms (102, 112, 206, 213, 222, 226, and 231) were inspected and found to be appropriately furnished for single occupancy. All rooms have a bed, nightstand, lamp, television, closet space, and overhead lighting. Rooms were clean, contained working fixtures, central air and heating, and a Vigil signal alert system. VOIP phone services are an option in every room. All bathrooms were functional and contained the required grab bars and non-slip material on the shower floor. Hot water temperature measured between 105 to 120-degree Fahrenheit.

Emergency Phone Numbers, Exit Plan & Menu:


The Emergency Disaster Plan with emergency phone numbers are posted & readily available for review near the concierge. The facility sketch and exit plan are mounted near every exit. Fire extinguishers were observed on both floors and in the kitchen.

Food Service:
Dishes, cups, flatware, and emergency food supply are stored in a secure commercial kitchen.

Smoke Detectors:
Santa Monica Fire Department conducted its inspection on 05/30/26. Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELBROOK SANTA MONICA
FACILITY NUMBER: 198320692
VISIT DATE: 09/11/2026
NARRATIVE
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Toxins:
Locked and stored in the laundry room, janitorial room, cleaning carts, and kitchen.

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are throughout the facility.

Clients & Staff Files:
Five resident records were reviewed and contained the required admission agreement, medical assessments, and pre-appraisals/plan of care. Five staff records were reviewed and contained the required criminal record clearances and health screenings.

Reading Material, Games, Equipment & Materials:
The facility has three activity areas to engage in interactive jeopardy games, listen to music, and host family gatherings.

Fire clearance:
Rooms approved for non-ambulatory/bedridden, approval of delayed egress or delayed egress with secured (locked) perimeter was approved on 06/30/26.

Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELBROOK SANTA MONICA
FACILITY NUMBER: 198320692
VISIT DATE: 09/11/2026
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Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5