195850105-12-22-2021-29-AS-EPEI-C9Y2VJ-20211222164402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850105
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:44:39 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) 266-5469
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 0	DATE:	12/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Edva Elkayam		TIME COMPLETED:	04:45 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 Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 2:00 p.m. LPA was greeted and screened by Administrator Edva Elkayam. This annual had a specific emphasis on infection control practices and procedures. The facility currently has zero (0) residents and the facility will be remodeling prior to accepting new residents. At 2:25 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 2:27 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 12:25 p.m. LPA observed the kitchen/dining area. Knives are stored in the locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 2:32 p.m. LPA observed hot water to be measured at 105.3-degree Fahrenheit. BEDROOMS: LPA observed model 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. There are eight (8) bedrooms, five (5) for resident use and three (3) staff use. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skids mats. At 2:32 p.m. LPA observed hot water to be measured at 113.5-degree Fahrenheit. Continued on LIC 809.

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)

Page: 1 of 3

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: 12/22/2021

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
26
27
28
29
30
31
32

Continued LIC 809.

COMMON AREAS: At 2:26 p.m., LPA observed common areas to be relatively clean and properly furnished. At 2: 25 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. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked near the kitchen area. Required postings were observed in the entryway.

The garage was converted to a laundry area with two (2) staff rooms. LPA requested for the building permits.

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.

At 2:10 p.m., LPA conducted Infection Control mitigation module with Administrator.

No deficiencies cited. Technical Assistance was issued. 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)

Page: 3 of 3