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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602726
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:33:32 PM

Document Has Been Signed on 02/01/2023 02:33 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: 6DATE:
02/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Heidi Schofield, Administrator TIME COMPLETED:
02:45 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 – Incident visit regarding self-reported incident. At 1:10 p.m., LPA and QA were greeted and screened by staff. At 1:23 p.m., the Administrator arrived at the facility.

This visit was regarding an incident report that was sent to Community Care Licensing (CCL) on 01/30/2023 and received on 01/31/2023. The incident report stated that on 01/29/2023, during the morning Staff #1 (S1) was assisting with the self-administration of Client #1's (C1's) medication and C1 got frustrated due to not being able to open the water bottle. C1 proceeded to spit out C1’s medication and S1 did not call the house manager or the Administrator to notify them of the incident. Afterwards S1 proceeded to give C1 the same medications. S1 called the house manager and the Administrator an hour after the incident. Once the Administrator and the house manager were notified of the incident, C1 was sent to the Emergency Room (ER) due them not knowing if C1 ingested any of the original morning medications or if any of the medications were given twice. The hospital took C1’s blood level and C1’s levels were normal and C1 was healthy and safe to be discharged back to the facility. Additionally, on 02/01/2023, C1 had a follow up appointment with C1’s Physicians. Additional blood work was ordered and C1’s Physicians noted no problems.
On 02/01/2023, LPA Peraldi conducted an interview with the Administrator. The Administrator stated that S1 was terminated on 01/30/2023. The Administrator stated that the medication error was unacceptable and that all staff have been trained recently regarding medication. The Administrator stated that on 01/30/2023, the Administrator conducted an all staff meeting regarding the medication error.
Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued for the amount of $250. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email and print.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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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Document Has Been Signed on 02/01/2023 02:33 PM - It Cannot Be Edited


Created By: Emily Peraldi On 02/01/2023 at 02:10 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: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2023
Section Cited
CCR
80075(b)

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80075(b) Health Related Services(b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Schedule a training regarding 80075 Health Related Services. Verification of scheduled training with the trainers credentials will need to be submitted by 02/02/2023 and completion of training must be submitted no later than 02/24/2023.
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Based on interviews, the licensee did not comply with the section cited above, as a medication error occurred on 01/29/23 regarding C1, which poses an immediate health and safety risk to clients in care.
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This is a repeat violation; civil penalty assessed in the amount of $250

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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: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
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