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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606094
Report Date: 05/12/2021
Date Signed: 05/12/2021 01:41:15 PM

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:SHALOM ELDERLY CARE, INC. #2FACILITY NUMBER:
197606094
ADMINISTRATOR:DINA VETCHTEINFACILITY TYPE:
740
ADDRESS:5738 WILHELMINA AVENUETELEPHONE:
(818) 710-8711
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 5DATE:
05/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dina Vetchtein - Administrator TIME COMPLETED:
02:00 PM
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LPA conducted an unannounced case management visit for the self-reported incident that occurred on 5-4-2021, where Resident #1 (R1) was observed chocking on food then transferred to the hospital. LPA met with Administrator Dina Vetchtein and explained the reason for the visit.

Between 12:30pm - 2:00pm, LPA conducted physical plant, reviewed facility files and obtained copies of documents pertinent to the incident. LPA also interviewed staff.

LPA did not observe any immediate health and safety issues during this visit. Further review required prior to LPA concluding the investigation of the incident received on 5-4-2021.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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