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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602726
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:03:48 PM

Document Has Been Signed on 02/14/2024 03:03 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
WOODLAND HILLS N.ASC, 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:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Heidi Schofield, Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:20 a.m., the LPA met with staff and explained the reason for the visit. At 9:40 a.m., the Administrator, Heidi Schofield and House Manager, Eduardo Briseno arrived at the facility.

Starting at 9:58 a.m., the LPA, along with the House Manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA observed the kitchen and dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:11 a.m., hot water temperature measured at 110.1-degree Fahrenheit. Knives are stored in a locked kitchen cabinet. Medications, and first aid kit are located in a locked kitchen cabinet.

BEDROOMS: The facility is a single-story residential home with six (6) bedrooms for client use and three (3) restrooms. The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Client restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid materials. Starting at 10:03 a.m., hot water temperature measured between 105.3 and 108.6 -degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: At 10:11 a.m., the LPA observed the back patio which has a covered outdoor area for client use. The LPA observed gardening activities for the clients. There are no bodies of water on the premises. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ETTA ISRAEL CENTER ADULT RESIDENTIAL #1
FACILITY NUMBER: 197602726
VISIT DATE: 02/14/2024
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GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/18/2023. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 10:10 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Facility telephone was observed during the time of the visit. Night lights were present in the hallways.

RECORD REVIEW: Between 2:20 p.m. and 4:36 p.m., the LPA conducted a file review for all clients and staff regularly scheduled and observed the following: Staff have current first aid. Client records were reviewed for, but not limited to current Individual Programming Plan (IPP), medical records, P & I funds, admissions agreement, and consent forms. All files were in order. The Administrator’s certificate is active and expires on 10/24/2024.

At 1:20 p.m., the LPA conducted a review of medication and medication documentation with the House Manager for four (4) clients and observed that medications were properly documented and assisted as prescribed.

Between 9:24 a.m. and 2:21 p.m., the LPA conducted interviews with two (2) clients and one (1) staff.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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