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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602726
Report Date: 04/19/2022
Date Signed: 04/19/2022 06:45:30 PM

Document Has Been Signed on 04/19/2022 06:45 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:ETTA ISRAEL CENTER ADULT RESIDENTIAL #1FACILITY NUMBER:
197602726
ADMINISTRATOR:HEIDI SCHOFIELDFACILITY TYPE:
735
ADDRESS:5520 WORTSER AVENUETELEPHONE:
(818) 785-2054
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 0DATE:
04/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Heidi Schofield, Administrator TIME COMPLETED:
06:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi and Rowena De Guzman, Community Services Specialist (QA) from North Los Angeles County Regional Center arrived to this location today for the purpose of conducting a Case Management – Deficiencies visit. At 1:50 p.m., LPA and QA were greeted and screened by staff. At 2:30 p.m., the Administrator arrived at the facility. Currently all of the clients are on vacation and will not be in the facility for eight (8) days.

During a previous visit on, 04/13/2022 at 9:38 a.m., LPA Peraldi arrived at the facility and knocked on the door. The facility appeared to be empty and no one answered the door. At 9:42 a.m., LPA Peraldi called the Administrator and the Administrator explained that a staff would be on the way to open the facility. Upon entry at 9:58 a.m., LPA Peraldi heard voices coming from room four (4). LPA Peraldi asked Staff #1 (S1) if all the client were at day program, S1 confirmed that all clients were at day program, except for Client #1 (C1). C1 recently had surgery and is in the process of recovering. During the day, C1 has a Personal Attendant (PA). The PA is not facility staff and is not associated to the facility. From 9:00 a.m. to the arrival of LPA Peraldi and S1 at 9:50 a.m., C1 was left alone at the facility with no staff, only the PA was present. During the time, C1 did not have the proper care and supervision as the PA is not facility staff.

On 04/15/2022 at 8:46 a.m., LPA Peraldi spoke with the Administrator and confirmed that C1 was left alone at the facility without care and supervision since the PA is not staff. The Administrator understood that C1 can not be left alone at the facility and stated that facility staff will remain at the facility whenever there are clients, including C1, present.

Contiued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 5
Document Has Been Signed on 04/19/2022 06:45 PM - It Cannot Be Edited


Created By: Emily Peraldi On 04/19/2022 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2022
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
The facility going forward will always have a staff present while clients are present. Within 24 hours, the Administrator will send LPA a date for training in regards to the above regulation.
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Based on observations and interviews, the licensee did not comply with the section cited by leaving C1 alone without facility staff on 04/13/2022 which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
04/20/2022
Section Cited
CCR80019(a)(2)(c)

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80019(a)(2)(C)Criminal Record Clearance (C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of 1338.5 or 1736.6, respectively...
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
Ensure that the PA or new PA have finger print clearance and associated to the facility. Within 24 hours, the Administrator will send LPA a date for training in regards to the above regulation.
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Based on observations and interviews, the licensee did not comply with the section cited above by having C1’s Personal Attendant (PA) working at the facility alone and not having criminal record clearance for the PA, which poses an immediate safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2022 06:45 PM - It Cannot Be Edited


Created By: Emily Peraldi On 04/19/2022 at 04:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
85068.3 (b)(1)

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85068.3 (b)(1) Modifications to Needs and Services Plan (b)If modifications to the plan identify an individual client service need which is not being met by the general program of facility services...(1) Consultation shall be secured from a dietitian, physician...
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
Update the Needs and Service Plan for C1 in accordance to the above regulation. The Administrator will send LPA proof of training in regards to the regulation by POC due date.
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Based on observations, interviews, and record reviews the licensee did not comply with the section cited above by not having C1’s Resident Records updated to reflect C1’s new needs and services, this includes but not limited to the Individual Program Planning (IPP) which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/03/2022
Section Cited
CCR80061(a)

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80061(a) Reporting Requirements
(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
The Administrator will send LPA proof of training in regards to the regulation by POC due date.
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Based on observations and interviews the licensee did not comply with the section cited above by not reporting an unusual incident report for an incident that occurred with C2 which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/19/2022 06:45 PM - It Cannot Be Edited


Created By: Emily Peraldi On 04/19/2022 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
80072(a)(8)

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80072 (a) (8)Personal Rights Not to be placed in any restraining device. Postural supports may be used under the following conditions:
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
Either remove the bed rails of C1 or get a written order from the client's physician for the bed rails by POC due date.
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Based on observations the licensee did not comply with the section cited above by C1 having half a bed rail without a written order from client’s physician which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726
VISIT DATE: 04/19/2022
NARRATIVE
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During todays visit, the LPA and QA toured the physical plant inside and outside. At 2:01 p.m., LPA and QA observed half bed rails in room #4. At 2:06 p.m., LPA and QA observed a patched drywall covering up a previous hole in the wall. Discussions with the Administrator and staff revealed that Client #2 (C2) punched the wall creating a hole. No incident reports were sent to Licensing or Regional Center. At 2:16 p.m., LPA and QA observed the backyard. The backyard has a fallen tree branch, a glass panel and potential hazardous materials throughout the backyard. The backyard glass sliding door is half covered with recycled bottles.
At 2:30 p.m., LPA and QA had a discussion with the Administrator regarding C1’s records. The Administrator explained that C1 does not have a care plan for the Right Choice In Home Care, which Right Choice did not provide.The Administrator stated that the Individual Program Planning (IPP) for the Regional Center is not currently updated to reflect C1’s new needs and services. The Administrator explained since the change is recent, the facility hasn’t received the addendum to the IPP.

The following recommendations were made:
- A deep cleaning of the house and kitchen also to include cleaning the air duct.
- Room 1 needs a bottom bed sheet.
- All rugs and mats need to be nonslip material.
- Electric cord on the side of the house is hanging.
- The recycle bottles need to be stored properly, not blocking an exit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil Penalties assessed in the amount of $500 and $500, for a total of $1,000.00 Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted and report reviewed with the Administrator. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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