197606094-2-7-2022-29-AS-ECAS-CBF3DC-20220207170918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606094
Report Date: 02/07/2022
Date Signed: 02/07/2022 05:12:11 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. #2		FACILITY NUMBER:	197606094
ADMINISTRATOR:	DINA VETCHTEIN		FACILITY TYPE:	740
ADDRESS:	5738 WILHELMINA AVENUE		TELEPHONE:	(818) 710-8711
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	02/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Doris Almario and Dina Vetchtein		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA’s) Elsie Campos and Ashley Smith arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff at 2:35 p.m. and explained the reason for the visit. Administrator Doris Almario arrived at the facility at 2:45 p.m and and Administrator Dina Vetchtein arrived a short time thereafter. The LPA’s toured the physical plant areas inside and outside, with Administrator Doris Almario at 2:50 p.m., to ensure there are no health and safety hazards. BEDROOMS: There are (4) four bedrooms designated for resident use. Bedroom #2, Bedroom # 3, Bedroom # 5 and Bedroom # 6 have a direct exit to the exterior. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Bedroom #1 is designated for staff. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA's observed sufficient amounts of soap and paper products. Hand-washing signs where identified in (2) two out of (3) restrooms. The LPA's advised the Administrators to ensure that bathrooms displayed appropriate hand-washing signs. Restroom hot water measured between 108.7 and 120.5 degrees Fahrenheit between 2:57 p.m. and 3:11 p.m. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 3:06 p.m. the LPA’s observed unlocked cleaning supplies under the kitchen sink. At 3:06 p.m. the LPA’s observed accessible knives and sharp objects in an unlocked drawer. At 3:07 p.m. the LPA’s observed sharp objects and a hammer in an unlocked drawer. Hot water measured at 108.5 degrees Fahrenheit at 3:09 p.m. Continued on LIC 809-C.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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 12

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: SHALOM ELDERLY CARE, INC. #2	FACILITY NUMBER: 197606094
	VISIT DATE: 02/07/2022

NARRATIVE

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COMMON SPACES: The common spaces included the living room and dining area. The LPA's observed cameras in all common spaces and a screened fireplace in the living room. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. All were tested at 3:20 p.m. and observed to be operational. The fire extinguisher was observed to be full and last bought on 03/21/21. The LPA's observed required postings on the wall of the living room. Flooring was checked for cleanliness and appeared in good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. At 3:11 p.m., the laundry area located inside bathroom #3 was unlocked, and there were accessible laundry supplies and chemicals. The Administrator secured it at the time of observation. At 5:02 p.m., the LPA observed accessible medications on the dining room table in small cups. The medication was secured at the time of observation.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Through the office is the garage which is attached to the home. The office contains additional nonperishable and perishable food items. At 3:13 p.m., the LPA’s observed pantry closet in office to have both food items and cleaning supplies.

INFECTION CONTROL: During today’s visit, the LPA's spoke with the Administrator Doris Almario regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. The LPA's also advised the Administrator to maintain a 30-day supply of Personal Protection Equipment (PPE). The Administrator requested additional surgical masks. 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 does not have a confirmed case of COVID-19 at this time and the LPA's reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via Email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC809 (FAS) - (06/04)

Page: 2 of 12

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: SHALOM ELDERLY CARE, INC. #2	FACILITY NUMBER: 197606094
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as in cleaning supplies were stored with non perishable foods which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/08/2022
	Plan of Correction
1 2 3 4	The administrator has agreed to do the following: 1. Separate all cleaning supplies and submit proof to CCL by POC date.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as sharp objects and dangerous tools were accesible, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/08/2022
	Plan of Correction
1 2 3 4	The administrator has agreed to do the following: 1. Secure all sharp and dangerous objects and submit proof to CCL by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC809 (FAS) - (06/04)

Page: 3 of 12

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: SHALOM ELDERLY CARE, INC. #2	FACILITY NUMBER: 197606094
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as cleaning supplies were accessible which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/08/2022
	Plan of Correction
1 2 3 4	The administrator has agreed to do the following: 1. Secure all cleaning supplies and submit proof to CCL by POC date.

Type A

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as medications were accessible on the dining room table, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/08/2022
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Secure the medications. This happened during today's visit. 2. Host an in-service training with staff, informing them of the policies and procedures around medication administration. Submit training sign in sheet no later than 2/11/2022.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC809 (FAS) - (06/04)

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