191201867-9-26-2023-29-AS-ZCHN-CW2UP3-20230926154453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191201867
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:46:26 PM

Document Has Been Signed on 09/26/2023 03:46 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EISENBERG VLG OF THE LA JEWISH HOME FOR THE AGING		FACILITY NUMBER:	191201867
ADMINISTRATOR:	GLASS, KATHLEEN K.		FACILITY TYPE:	740
ADDRESS:	18855 VICTORY BOULEVARD		TELEPHONE:	(818) 774-3000
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 271		CENSUS: 101	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Kathleen K. Glass		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Zabel Chochian and Brian Balisi conducted the Required Annual visit for this facility today. Upon arrival LPAs met with Executive Director Kathleen Glass and reason for visit was stated. Entrance interview conducted. At approximately (approx) 10am, LPA Brian Balisi, Allison Tepper - Assistant Administrator and Alvin Ofresio, Clinical Manager toured the facility physical plant areas inside and out. KITCHEN: At 10:05am observed Kitchen and dining room located in the Pepp Center. The kitchen was observed to be inaccessible to residents in care. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. 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. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 01/30/2023. The LPA observed required postings near the entrance way. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. At approx. 11am - LPA observed three (3) residents doing arts and crafts in the Borun Arts and Craft building in the Weinburg building. BEDROOMS: At approx. 10:16 a.m. LPA observed thirteen (13) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens. Resident pendants were tested in each room, LPA observed staff arrive in a timely manner to assist resident. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in resident rooms (#110, 122, 121, 162, 154, 220, 235, 233, 242, 208, 251, 207) ranged between 106.9 – 112.3*f. (Continue to LIC809c)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EISENBERG VLG OF THE LA JEWISH HOME FOR THE AGING	FACILITY NUMBER: 191201867
	VISIT DATE: 09/26/2023

NARRATIVE

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The Weinburg building is currently not in use for resident care. LPA observed it to be empty at this time. It is currently used to store extra office supplies. Doors are locked and inaccessible to residents and it is monitored by guards in the evening. OUTSIDE GROUNDS: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents use. LPA observed a fountain in the courtyard which was filled with rocks. No pool on the premises.

MEDICATIONS: Medications review began at 11:25 a.m. The medications are centrally stored in the medication rooms on the 1st and 2nd floor. Both medication rooms were reviewed during the visit. LPA reviewed medications for nine (9) residents. Medications are labeled and checked for expiration dates. Medications including PRN’s are properly documented on the centrally stored medications and destruction record. The LPA observed PRNs to have physicians order on file. No errors observed during review.

At approximately 12:05pm, LPA observed residents having lunch in the dining room. Between 10:15am - 12:00 p.m., LPA interviewed six (6) residents and six (6) staff.

STAFF/RESIDENT RECORDS reviewed from 10am-2:30pm: LPA reviewed 10 staff records. Staff are fingerprint cleared. LPA observed the Administrator certificate to be valid until 11/2023. All 10 staff have current first aid and CPR. Training records were observed; medications training and ongoing training per the health and safety codes 1569.69 and 1569.625. Mrs. Glass stated that she will implement a training log for future use for better tracking completed training. LPA reviewed a sample of ten (10) resident records. LPA reviewed records for Admissions agreements, Appraisal Needs and Service plans, Resident Appraisals, Medical Assessment (Physicians Reports), TB results, consents, list of personal property and Personal Rights. Resident files were missing the personal rights form (LIC613c). LPA did observe a section on personal rights in the residents admission agreement. Mrs. Glass was provided with the Personal Rights form LIC613C. Mrs. Glass stated that she will work on getting all residents this form signed and filed in the resident files. An advisory was provided.
Transportation vehicle checked at approx. 2:45pm - Pre-trip inspection conducted daily; service maintenance conducted every 5000 miles; insurance and registration checked; vehicle observed during visit.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.
LPAs obtained the following documents - Resident roster, LIC 500, and copy of the Limited Liability insurance. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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