197607119-9-14-2024-31-AS-ADUA-D94VJG-20240914162842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607119
Report Date: 09/14/2024
Date Signed: 09/14/2024 04:28:48 PM

Document Has Been Signed on 09/14/2024 04:28 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 III		FACILITY NUMBER:	197607119
ADMINISTRATOR:	RITA SHER		FACILITY TYPE:	740
ADDRESS:	745 NORTH HARPER AVENUE		TELEPHONE:	(818) 438-4045
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	6	CENSUS: 5	DATE:	09/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:49 PM
MET WITH:	Rita Sher		TIME COMPLETED:	04:30 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) Abeye Duguma met with Rita Sher for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 01:00 PM 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 75°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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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 III	FACILITY NUMBER: 197607119
	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 111.3°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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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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