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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607118
Report Date: 09/14/2024
Date Signed: 09/14/2024 12:49:24 PM


Document Has Been Signed on 09/14/2024 12:49 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:A SHALOM GARDEN IIFACILITY NUMBER:
197607118
ADMINISTRATOR:RITA SHERFACILITY TYPE:
740
ADDRESS:743 NORTH HARPER AVENUETELEPHONE:
(818) 438-4045
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 5DATE:
09/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Milagros CelestinoTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Milagros Celestino for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:00 AM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of five (05) bedrooms and six (06) bathrooms. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for three (03). The facility is currently occupying five (05) residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the hallway, observed to be fully charged and last inspected on 08/20/2024.

(continued on LIC 809-C)

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2024
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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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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A SHALOM GARDEN II
FACILITY NUMBER: 197607118
VISIT DATE: 09/14/2024
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 112.8°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC809 (FAS) - (06/04)
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