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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602726
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:53:28 PM

Document Has Been Signed on 03/12/2024 03:53 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:
03/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Heidi Schofield, Allen Remer, Hillary KesslerTIME COMPLETED:
03:52 PM
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An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. In attendance included Licensing Program Manager (LPM) Kristin Heffernan, Licensing Program Analyst (LPA) Emily Peraldi, Administrator Heidi Schofield, Director of Administration, Allen Remer and Director of Client Services, Hillary Kessler.

LPM Heffernan discussed substantiated complaints and citations issued from the past three years. During this informal office meeting, a discussion was held regarding modifications that need to be made in order to be in compliance with Fire and CCLD’s requirements.

On July 7th, 2023, the Administrator requested a non-ambulatory request for Resident #1 and LPA Peraldi advised the Administrator that a new fire clearance and fire inspection would be needed. LPA Peraldi also requested for the facility sketch, walker script and the LIC200- APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY FOR THE ELDERLY LICENSE to change the ambulatory status of the facility. On July 7th, 2023, and on July 18, 2023, the Administrator sent the LPA a LIC 200. On October 5, 2023, Fire Inspector Benjamin Guzman conducted an inspection and provided a list of corrections in order to be granted the non-ambulatory status. On February 21, 2024, the Administrator requested a non-ambulatory request for Resident #2. The facility is requesting to change the six (6) Ambulatory only to three (3) non-Ambulatory and (3) Ambulatory.

Allen Remer stated that the facility has been working on the change of ambulatory status for a long time, including hiring a construction company. Remer stated that the construction required for the non-ambulatory status includes but not limit to widening all doorways, redoing bathrooms, exterior structure change. At the moment, the Licensee has signed with a construction company and will be meeting with them on March 14, 2024 for a detailed construction plan and schedule. It is estimated that the construction will take three (3) months to complete. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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: 03/12/2024
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LPM Heffernan asked for a plan as to how clients will minimally impacted by the construction. Remer explained that the construction company will be working on one room at a time in order to minimize any disruption on clients daily living. LPM Heffernan requested the following: building permits, updated facility sketch, plan for construction, and schedule for construction. The Administrator stated that the requested documentation will be sent to the Department as soon as it is acquired. Licensee representatives agreed to keep CCLD updated throughout the construction process and future Fire Inspection.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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