195850104-12-22-2021-29-AS-EPEI-C9XTJT-20211222134651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850104
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:47:41 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) 585-7778
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 3	DATE:	12/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Edva Elkayam		TIME COMPLETED:	01:50 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 12:00 p.m. LPA was greeted and screened by Administrator Edva Elkayam. This annual had a specific emphasis on infection control practices and procedures. At 12:18 p.m. LPA and Administrator began the physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Title 22 Regulations. OUTDOOR SPACE: At 12:23 p.m., LPA observed the backyard, which has a covered outdoor area for resident use. There is a latch on the side gate for emergency exits. KITCHEN: At 12:26 p.m. LPA observed the kitchen/dining area. Knives are stored in the locked kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:27 p.m., LPA observed staff cleaning the kitchen. At 12:55 p.m. LPA observed hot water to be measured at 110.6-degree Fahrenheit. BEDROOMS: LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level. Nightlights were present in the hallways outside non-private bathrooms. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skids mats. At 12:34 p.m. LPA observed hot water to be measured at 106.7-degree Fahrenheit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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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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: 12/22/2021

NARRATIVE

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Continued from LIC 809

COMMON AREAS: At 12:26 p.m., LPA observed common areas to be relatively clean and properly furnished. At 12:05 p.m., LPA observed the fire extinguisher charged and last serviced on 11/12/2021. Medications and first aid kits are in a locked medication cabinet located near the kitchen area.

GARAGE: The garage is locked and attached to the house and facility records are in the locked garage. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The garage also has two extra refrigerators. The laundry machines are located in the garage.

Required postings were observed in the entryway. All exits had a functioning auditory device.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

At 12:10 p.m., LPA conducted Infection Control mitigation module with Administrator.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC809 (FAS) - (06/04)

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