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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602726
Report Date: 10/31/2024
Date Signed: 10/31/2024 02:18:32 PM

Document Has Been Signed on 10/31/2024 02:18 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/
DIRECTOR:		HEIDI SCHOFIELDFACILITY TYPE:
735
ADDRESS:5520 WORTSER AVENUETELEPHONE:
(818) 785-2054
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 6DATE:
10/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:57 PM
MET WITH:Residential Supervisor- Eduardo Jr BrisenoTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a case management visit regarding fire clearance and entered the facility at 1:57pm Upon arrival, LPA Mosley was greeted by Residential Supervisor. The LPA met with Residential Supervisor Eduardo Jr Briseno and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

The facility was cleared and approved on 10/10/2024 for Three (3) non-ambulatory in rooms #1, #3, and #6. Cleared and approved for Three (3) ambulatory with a total of six (6) capacity. All bedrooms were observed and follow the fire inspection.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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