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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201867
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:48:45 PM

Document Has Been Signed on 09/15/2022 01:48 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
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: 106DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Kathleen GlassTIME COMPLETED:
01:59 PM
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At 11:50 a.m. on 09/15/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. The facility was last visited on 08/18/2021 for an annual visit. It is a two story building with 68 bedrooms, kitchen, laundry room, common areas, lounges, and outdoor areas. It has an approved fire clearance for 247 ambulatory residents and 24 non-ambulatory residents. Approved hospice waivers for 6. The facility uses surveillance cameras in common areas.

The facility screens all visitors, staff, and residents at the main entrance. LPA was screened at the front gate and provided a visitor badge. Staff recorded temperature, symptoms, and vaccination status. Signs posted at the main entrance included facility license, Administrator certificate, personal rights, Emergency Disaster Plan, Ombudsman contacts, confidential complaint contacts, Provider Information Notices (PINs), and the facility’s masking requirement. Posted throughout the facility were the weekly food menu, activity calendars, facility maps with evacuation routes labelled, hand sanitizer stations, and COVID precautions. At 12:15 p.m. LPA measured the internal temperature to be 76 degrees Fahrenheit. Medication rooms were locked and attended. Social distance reminders were present around the medication rooms, and furniture was arranged to provide social distance. All bedrooms were shared bedrooms which contained a chair, nightstand, lamp, storage, private bathroom, pull-cord call systems, and beds with adequate bedding. All furnishings were clean and in good condition. At 12:53 p.m. LPA measured the water temperature in a resident bathroom to be 119.5 degrees Fahrenheit. The Administrator confirmed that HEPA filters are provided if resident isolation is required. Facility wide testing is conducted on a weekly basis. Seating in the dining room allowed for social distance. The facility uses HEPA filters in the dining room as well.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EISENBERG VLG OF THE LA JEWISH HOME FOR THE AGING
FACILITY NUMBER: 191201867
VISIT DATE: 09/15/2022
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LPA and Administrator toured the laundry and kitchen areas. LPA observed an adequate supply of perishable and non-perishable food. The facility maintained a Kosher kitchen where meats and dairy are prepared separately. All kitchen staff were wearing KN95 masks. At approximately 12:58 p.m. LPA observed the refrigerator and freezer temperature logs. All temperatures were within regulations. Appliances were sanitary and functional. Housekeeping separated resident laundry by location. The laundry area also contained a separate room and machines for laundry from residents with COVID. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Lounge areas contained reading materials, activities, and snacks. Residents were observed walking outdoors in walkways. The designated visitation area was shaded with furniture in good repair. Benches and outdoor activities were present. The gardened areas were maintained. All emergency exit paths were free from obstructions. At approximately 12:40 p.m. LPA observed fully charged fire extinguishers in the hallways. They were last inspected on 08/28/2022. At approximately 12:45 p.m. LPA reviewed records from the most recent facility tests. Elevators, generators, and fire systems all passed inspections on 07/13/2022. The carbon monoxide detector was tested and functioning at 1:11 p.m. Fire sprinklers were located in bedrooms, hallways, and common areas. Emergency water supplies are located near the laundry room.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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