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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602726
Report Date: 02/22/2022
Date Signed: 02/22/2022 01:47:27 PM

Document Has Been Signed on 02/22/2022 01:47 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:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Samuel Forman, House ManagerTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 12:15 p.m. LPA was greeted and screened by house manager, Samuel Forman. The Administrator was not available at the time of the visit and authorized staff, Samuel Forman to sign the report. This annual had a specific emphasis on infection control practices and procedures. At the time of the visit, the clients were at day program.

At 12:40 p.m. LPA and staff 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.

COMMON AREAS: At 12:41 p.m., LPA observed common areas to be relatively clean and properly furnished. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. Required signs such as the license and complaint poster are posted around the facility. At 12:44 p.m., LPA observed the fire extinguisher to be fully charged and last serviced on 09/30/2021.

KITCHEN: At 12:45 p.m., LPA observed the kitchen/dining area. Knives are stored in the locked kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:45 p.m., kitchen hot water temperature measured at 108.8-degree Fahrenheit. Medications and first aid kit are located in a locked kitchen cabinet.

BEDROOMS: At 12:49 p.m., LPA observed multiple client 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.

Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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 2
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: 02/22/2022
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Continued from LIC 809.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition. Restrooms had sufficient supply of hand soap and paper products. Night lights were present in the hallways and passages to nonprivate bathrooms. At 12:55 p.m. LPA observed hot water to be measured at 106.8-degree Fahrenheit.

OUTDOOR SPACE: At 12:51 p.m., LPA observed the backyard, which has a covered outdoor area for client use. The facility has a side gate with a latch for emergency exits.

GARAGE: Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage. The garage also has extra supplies such as paper products and food.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff 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. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

Between 12:26 p.m. – 12:40 p.m., LPA conducted Infection Control mitigation module with staff.

No deficiencies cited. Exit interview conducted. A copy of the report will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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