195850105-11-4-2020-29-AS-EMIR-BV2VCC-20201104151856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850105
Report Date: 11/04/2020
Date Signed: 11/04/2020 03:19:00 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 4, THE		FACILITY NUMBER:	195850105
ADMINISTRATOR:	ELKAYAM, ISRAELA		FACILITY TYPE:	740
ADDRESS:	5430 TYRONE AVENUE		TELEPHONE:	(818) 508-7010
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 3	DATE:	11/04/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Israela Elkayam		TIME COMPLETED:	03:30 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 Israela 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, five (5) of which may be non-ambulatory and one (1) of which may be bedridden on 07/24/20. The facility is currently operating as CARMEL - 4 - 191222677 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. Hot water delivered at 112F. There was sufficient perishable food to accommodate a maximum capacity of six (6) Residents for two (2) days. There was sufficient nonperishable food to accommodate a maximum capacity of 6 Residents for seven (7) days. The medications and First Aid Kit are located in a cabinet between the Kitchen and Bedroom #1 and are kept inaccessible to Residents. There were no visible immediate hazards or discrepancies observed.. BEDROOMS: There are six (6) Bedrooms, five (5) of which are designated for Resident use and one (1) for Staff use. Resident bedrooms #2, 3, 4 & 6 are furnished for single occupancy. Resident bedroom # 5 is furnished for double occupancy. Bedroom #1 is designated for staff use and is kept inaccessible to Residents. All bedrooms were appropriately furnished and supplied with linens and bedding. There were no visible hazards or discrepancies.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

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 4, THE	FACILITY NUMBER: 195850105
	VISIT DATE: 11/04/2020

NARRATIVE

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BATHROOMS: There are three (3) Bathrooms, two (2) Full baths and one (1) half bath. The half bath is located inside Bedroom #1 and is designated for the use of the assigned occupant only. The two full bathrooms are located in the vicinity of Bedrooms 3, 4, 5 & 6 and are designated for use by both Residents and Staff. All bathrooms were equipped with appropriate grab bars and supplied with necessary paper and hygiene items. There were no immediate hazards or discrepancies observed.

COMMON AREAS: These include the Living Room and Dining Room. The common areas were appropriately furnished to accommodate a maximum capacity of 6 Resident. Required postings were located inside the main entrance. There was a hand sanitizing station inside the main entrance. Required COVID-19 Postings for the exterior of the main entrance were missing.

GARAGE & LAUNDRY: Entrance to the garage is exterior only. The laundry appliances are located in the garage which is also used for general storage. The garage is kept inaccessible to Residents.

SURROUNDING GROUNDS: The property is fenced and gated. The front yard includes lawn areas and a paved driveway. The backyard includes lawn and landscaped areas, a patio with furniture appropriate for outdoor use and an umbrella for shade. There is a wheelchair accessible ramp. There were no immediate visible hazards or discrepancies observed.

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: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC809 (FAS) - (06/04)

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