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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606744
Report Date: 10/12/2022
Date Signed: 10/12/2022 09:43:21 AM

Document Has Been Signed on 10/12/2022 09:43 AM - 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:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Heidi Schofield, AdministratorTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. Upon arrival, staff notified the LPA that five (5) out of six (6) clients went to their homes in observation of the Jewish holiday. There was one (1) client residing at the facility, whom left for day program. In addition, the facility was being painted at the time of the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.

KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The client rooms were furnished appropriately; beds had with clean linens and rooms had sufficient lighting. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 9:00 a.m., water temperature in a client restroom measured at 126.2 F, which is outside of the required range of 105-120 degrees F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Fire extinguishers were fully charged, yet they were serviced 9/2021. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. No bodies of water noted. The garage is attached, but was locked.

INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry. Infection Control signs were observed throughout the facility and additional ones would be posted upon completion of painting. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation and vaccine requirements. The facility managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility's procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC809-D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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Document Has Been Signed on 10/12/2022 09:43 AM - It Cannot Be Edited


Created By: Ashley Smith On 10/12/2022 at 09:31 AM
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: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming 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 did not comply with the section cited above, as the water temperature measured outside of the required range, which poses an immediate health and safety to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Adjust the water tank within the next 24 hours
2. After adjusting the water, keep a five day temperature log and submit to CCL within the next seven days
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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