195850184-12-22-2021-29-AS-EPEI-C9Y2WE-20211222164526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850184
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:46:12 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:	COTTAGES AT THE COLONY OF SHERMAN OAKS #4		FACILITY NUMBER:	195850184
ADMINISTRATOR:	LEVENTER, DVORA		FACILITY TYPE:	740
ADDRESS:	5430 TYRONE AVENUE		TELEPHONE:	(818) 479-3700
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 0	DATE:	12/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Edva Elkayam		TIME COMPLETED:	04:47 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	At 2:00 p.m., Licensing Program Analyst (LPA), Emily Peraldi, conducted a pre-licensing visit to this property with applicant representative Edva Elkayam. This is a change of ownership application from The Colony Sherman Oaks #4 (#195850105) to Cottages at the Colony of Sherman Oaks #4 (#195850184). The current census is 0 residents. On 09/09/2021, the applicant obtained fire clearance for a total capacity of one (1) bedridden resident and five (5) non-ambulatory residents. Between 2:25 p.m.- 2:55 p.m. LPA, along with applicant toured the facility. At 2:26 p.m., LPA toured the kitchen area. The facility has a sufficient supply of perishable and non-perishable food. Kitchen knives are stored in a locked cabinet. Appliances and all equipment appear to be clean and in good repair. The kitchen has a sufficient supply of plates, cups, cook ware and utensils. The freezer and refrigerator are at proper temperature range. At 2:32 p.m. hot water measured at 105.3 degrees Fahrenheit. At 2:30 p.m., fire alarms and carbon monoxide detectors were tested and were functioning properly. LPA observed the fire extinguisher to be fully charged and last serviced on 11/12/2021. There are eight (8) bedrooms, five (5) for resident use and there are three (3) staff rooms. The model bedrooms are equipped with clean mattresses, pillows, bedding, a dresser and closet space. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. There is a total of three (3) bathrooms. Bathrooms have sufficient paper products and soap. At 2:32 p.m. bathroom hot water measured to 113.5 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: COTTAGES AT THE COLONY OF SHERMAN OAKS #4	FACILITY NUMBER: 195850184
	VISIT DATE: 12/22/2021

NARRATIVE

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Continued from LIC 809

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Facility has a working telephone for resident use. Facility has activity supplies such as board games.

Medications and first aid kits are in a locked medication cabinet located near the kitchen. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away near the kitchen. Facility records will be kept in a locked cabinet near the kitchen.

The facility has a central entry point for universal screening. Alcohol-based hand sanitizer is available upon entry. Signs are posted throughout the facility to promote handwashing, and cough/sneeze etiquette. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE). The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Client Personal Rights, and Facility Theft and Loss Program.

There is adequate supply of emergency water, along with emergency nonperishable food. There are no firearms/ammunition stored on the property. There are no bodies of water on the premises at the time of the visit. At 2:26 p.m. the LPA observed the back patio, which has a covered outdoor area for resident use. There is a latch on the side gate for emergency exits. The exterior passageways were clean and clear of any obstructions.

The garage was converted into a laundry area with two (2) staff rooms. LPA requested for the building permits. LPA will clarify with the fire inspector about the facilities fire clearance prior to licensure. The laundry area and staff rooms will be kept inaccessible to residents. Physical plant is not consistent with the submitted facility sketch/floor plan.

At 4:15 p.m. LPA conducted the pre-licensing inspection tool.
On 12/21/2021 at 3:30 p.m. Comp III was conducted. Applicant has not completed Component II yet.

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

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: COTTAGES AT THE COLONY OF SHERMAN OAKS #4	FACILITY NUMBER: 195850184
	VISIT DATE: 12/22/2021

NARRATIVE

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Contuied from LIC 809-C.

During the inspection, the LPA observed the following corrections needed prior to licensure:
- Submit building permit for the conversion of the garage.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

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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