195850104-12-1-2020-29-AS-EMIR-BVVUFQ-20201201143307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850104
Report Date: 12/01/2020
Date Signed: 12/01/2020 02:33:11 PM

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:	COLONY - SHERMAN OAKS 3, THE		FACILITY NUMBER:	195850104
ADMINISTRATOR:	ELKAYAM, EDVA		FACILITY TYPE:	740
ADDRESS:	5426 TYRONE AVENUE		TELEPHONE:	(818) 909-0333
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 2	DATE:	12/01/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Edva Elkayam		TIME COMPLETED:	02:30 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 Analyst (LPA) Eva Miller conducted a Pre-Licensing Inspection with Administrator Edva Elkayam. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime". An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 4/22/20. A Fire Clearance was approved for a maximum capacity of six (6) residents, all of which may be bedridden, on 07/17/20. The facility is currently operating as CARMEL - 3 - 197604349 and licensed to "Carmel Residential Care Inc.". The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Sherman Oaks, CA. A tour of the physical plant was conducted and the following observed: KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable food to accommodate a maximum capacity of six (6) residents for a minimum of two (2) days. There was sufficient nonperishable food to accommodate a maximum capacity of 6 residents for (seven) 7 days. Hot water delivered at 115F. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 Residents. First Aid Kit and Resident Medications are located in a secured cabinet. There were no visible immediate hazards or discrepancies observed.. BEDROOMS: There are seven (7) Bedrooms, 6 of which are designated for Resident use. Bedroom #7 is designated for staff use and is kept inaccessible to residents. The bedrooms are furnished for single occupancy. There was appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

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: COLONY - SHERMAN OAKS 3, THE	FACILITY NUMBER: 195850104
	VISIT DATE: 12/01/2020

NARRATIVE

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BATHROOMS: There are three (3) full Bathrooms and two (2) half baths. The full bathrooms are located inside Bedroom #1, between bedrooms #2 & 3 and across from bedroom #4. Bedrooms 5 & 6 each have a half bath inside. The bathrooms located inside Bedrooms are designated for the occupying residents only. All other bathrooms are designated for both resident and staff use. All bathrooms are equipped with required grab bars and supplied with appropriate paper and hygiene products. There were no visible hazards or discrepancies.

COMMON AREAS: These include the Living Room and Dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. All required postings were located inside the main entrance and/or the Dining Room. There was a hand sanitizing station inside the main entry. Required COVID-19 postings were located at the main entrance both interior and exterior and throughout the facility. There were no visible hazards or discrepancies.

GARAGE & LAUNDRY: The laundry appliances and supplies are located inside the garage. The garage is accessible to Staff only.

SURROUNDING GROUNDS: The Front Yard is fenced and gated and includes a driveway, paved walkways and landscaped garden areas. The backyard includes landscaped areas, a patio, furniture appropriate for outdoor use and shade. There were no visible immediate hazards or deficiencies.

The following will be required before a license may be issued:

FACILITY SKETCH - YARD (LIC 999)

A copy of the Licensing Report was provided via email for signature and return.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

LIC809 (FAS) - (06/04)

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