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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607119
Report Date: 08/20/2022
Date Signed: 08/20/2022 02:07:58 PM


Document Has Been Signed on 08/20/2022 02:07 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 IIIFACILITY NUMBER:
197607119
ADMINISTRATOR:RITA SHERFACILITY TYPE:
740
ADDRESS:745 NORTH HARPER AVENUETELEPHONE:
(818) 438-4045
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 3DATE:
08/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Rita SherTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Rita Sher and caregiver Ferdinand Jayo who was designated by the administrator as the signee to accept this report. for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:50pm and the following was noted:

There is one entrance being utilized at the facility, there are required posters at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has enough PPE supplies. 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 three (03) non-ambulatory 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. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) 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. Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are observed to be operational. Fire extinguisher is located in the hallway, observed to be full and last inspected on 08/18/2022.
(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: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2022
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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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 III
FACILITY NUMBER: 197607119
VISIT DATE: 08/20/2022
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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 113.2°F. Towels and washcloths are not shared. There was enough clean linen available in each room's dresser. LPA observed medication and first aid kit to be locked and inaccessible to residents.


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: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2022
LIC809 (FAS) - (06/04)
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