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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201867
Report Date: 08/18/2021
Date Signed: 08/18/2021 11:51:10 AM

Document Has Been Signed on 08/18/2021 11:51 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EISENBERG VLG OF THE LA JEWISH HOME FOR THE AGINGFACILITY NUMBER:
191201867
ADMINISTRATOR:GLASS, KATHLEEN K.FACILITY TYPE:
740
ADDRESS:18855 VICTORY BOULEVARDTELEPHONE:
(818) 774-3000
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 271CENSUS: 115DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kathleen Glass/ AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Patrick Shanahan arrived at the facility in order to conduct an infection control annual visit. LPA had his temperature checked at the gate, before entry, and was provided with a face shield.

Once the LPA was in the facility, the administrator, Kathleen Glass and the Safety Coordinator, Susan Leitch, gave the LPA a tour of the facility.

Signs were were observed through out the facility, reminding residents to wear their masks and to wash their hands frequently. Hand sanitizer was observed through out the facility.

All common areas were observed to be spread out and promoted social distancing.

At 10:35 am, the kitchen and dining areas were observed to be clean and hand sanitizer is available on all tables. All tables have been spread out and currently only 2 people per table are allowed.

No deficiencies or health and safety concerns were observed during todays visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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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