195850246-7-25-2023-29-AS-ZCHN-CU466N-20230725203214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850246
Report Date: 07/25/2023
Date Signed: 07/25/2023 08:32:44 PM

Document Has Been Signed on 07/25/2023 08:32 PM - It Cannot Be Edited

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:	WALNUT GARDEN III		FACILITY NUMBER:	195850246
ADMINISTRATOR:	ILLOUZ, IZHAK		FACILITY TYPE:	740
ADDRESS:	12802 COLLINS STREET		TELEPHONE:	(818) 624-1918
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	07/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Izhak Illouz		TIME COMPLETED:	06:00 PM

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Licensing Program Analyst (LPA) Zabel Chochian conducted an annual inspection visit today. Upon arrival LPA met with staff. Licensee/Administrator was contacted and arrived at approximately 1:30pm. LPA and staff initiated the physical plant tour approximately 1:15pm and later continued the tour with Mr. Illouz.

BEDROOMS: There are (7) seven bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (1) one staff room. The staff room is kept locked. Room #3, #5 and #7 have direct access to the outside. Lighting in the rooms are adequate. (6) six out of (6) six private resident rooms observed with beds, night stands, lamps, chests of drawers, chairs and closet space. BATHROOMS: Six (6) full bathrooms. There are five (5) private bathrooms for resident use; the full bathroom near the entrance of the home next to the kitchen is designated for staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between required range 110.5 degrees Fahrenheit. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. There are three (3) fire extinguishers which were fully charged and last serviced 4/27/2023. There is a functioning telephone on the premises. All required postings observed posted on the wall in the kitchen. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises. The back and sides of the house are separated from the front yard by gates at the north and south side passageways, both gates have self-latching mechanisms. There is no front yard gate or driveway gate. The garage on the property has been converted into a residential unit with a separate address which in not attached to the house. There are no other structures on the property.

continue to LIC809c..

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

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: WALNUT GARDEN III	FACILITY NUMBER: 195850246
	VISIT DATE: 07/25/2023

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STAFF RECORDS: Reviewed at approximately 2pm; LPA with the assistance of Mr. Illouz reviewed all staff files. Staff first-aid/cpr certificates, TB clearance and fingerprint clearance observed for staff on duty including the private caregiver. Training records observed on file for staff. LPA was informed that staff have not completed the medication training therefore a trained staff from the sister facility or assistant administrator will administer the residents medication until current staff complete required medication staff. Also technical violation was issued to ensure the new staff receive the required number of hours of training for the year.

RESIDENT RECORDS: Reviewed at approximately 2:45pm - LPA with the assistance of Mr. Illouz reviewed all resident files. Files included admission agreements, medical assessments, personal rights documents, consent forms, lists of personal property, current appraisals.

MEDICATIONS: Medications are in a locked cabinet in the kitchen. Medications and records reviewed for three out six residents during todays visit at approximately 3:45pm. Medications are consistent with the logs on file. Doctor's orders for medications are in file.

Facility has an Emergency and Disaster plan at the facility.

No deficiencies observed. Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC809 (FAS) - (06/04)

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