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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606744
Report Date: 09/20/2021
Date Signed: 09/20/2021 04:04:58 PM

Document Has Been Signed on 09/20/2021 04:04 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ETTA ISRAEL CENTER ADULT RESIDENTIAL #3FACILITY NUMBER:
197606744
ADMINISTRATOR:HEIDI SCHOFIELDFACILITY TYPE:
735
ADDRESS:12655 EMELITA AVENUETELEPHONE:
(818) 358-3008
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Heidi Schofield, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 12:40 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Heidi Schofield at 01:15 p.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside at 12:59 p.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the client bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Client restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom.
Between 01:09 p.m. and 01:34 p.m., hot water temperatures measured between 90.2 and 100.6 degrees Fahrenheit in the kitchen, common, and private bathroom(s). The LPA advised the Administrator hot water temperature is to attain a temperature of not less than 105 degrees Fahrenheit (41 degree C) and not more than 120 degrees Fahrenheit (49 degree C). The hot water temperature was adjusted to attain correct temperatures during visit. Plan of correction was met during visit.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. Two (2) fire extinguishers were observed to be fully charged with a date 04/2021.
Continued on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #3
FACILITY NUMBER: 197606744
VISIT DATE: 09/20/2021
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BACKYARD: The backyard has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted. The garage contains additional nonperishable and perishable food items. The garage is detached to the facility. At 01:18 p.m., assessable poisons were observed to be in the backyard unsecured and assessable to clients. The Administrator immediately secured the poisons during the physical plant tour. Plan of correction was met during visit.


INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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 reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2021 04:04 PM - It Cannot Be Edited


Created By: Salia Walker On 09/20/2021 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETTA ISRAEL CENTER ADULT RESIDENTIAL #3
FACILITY NUMBER: 197606744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies: (e)Faucets used by clients.. shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees Fahrenheit in the kitchen, common, and private bathroom(s), which poses a potential immediate health, and safety risk to clients in care.
POC Due Date: 09/20/2021
Plan of Correction
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Hot water temperature was adjusted to attain correct temperatures during visit. Plan of correction was met during visit.
Type A
Section Cited
CCR
80087(g)(1)
80087(g)(1) Buildings and Grounds: (g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee failed to ensure poisons, and other items that could pose a danger if readily available to clients were be stored where inaccessible to clients, which poses an immediate health, and safety risk to clients in care.
POC Due Date: 09/20/2021
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit a completion of retraining for staff log: CCR Section Code 80087(g)(1) by 09/27/2021.
The Administrator immediately secured the poisons during the physical plant tour.
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
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
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