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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608309
Report Date: 05/22/2022
Date Signed: 05/22/2022 11:31:28 AM

Document Has Been Signed on 05/22/2022 11:31 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 #4FACILITY NUMBER:
197608309
ADMINISTRATOR:HEIDI SCHOFIELDFACILITY TYPE:
735
ADDRESS:6101 BLUEBELLTELEPHONE:
(818) 980-1709
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
05/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Claudia Matias Hernandez, StaffTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:58 a.m., the LPA was greeted and screened by staff, Claudia Matias Hernandez. The Administrator was not available at the time of the visit and authorized staff, Claudia Matias Hernandez to sign the report. This annual had a specific emphasis on infection control practices and procedures.

At 10:17 a.m., the LPA and staff began the physical plant tour inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with the Title 22 Regulations.

KITCHEN: At 10:17 a.m., the LPA observed the kitchen/dining area. Knives are stored in the locked cabinet near the kitchen area. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:22 a.m., kitchen hot water temperature measured at 117.2-degree Fahrenheit.

COMMON AREAS: At 10:20 a.m., the LPA observed common areas to be relatively clean and properly furnished. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. At 10:40 a.m., fire alarms and carbon monoxide detectors were tested and functioned properly. At 10:43 a.m., the LPA observed the fire extinguisher to be fully charged and serviced on 09/2021. Medications and first aid kits are located in a locked cabinet near the living area. At 10:56 a.m., the LPA observed staff and clients playing a game of UNO. The laundry units are located inside the laundry room.

BEDROOMS: At 10:22 a.m., the LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ETTA ISRAEL CENTER #4
FACILITY NUMBER: 197608309
VISIT DATE: 05/22/2022
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RESTROOMS: The facility has two (2) restrooms which are relatively clean and sanitary and in operating condition. Restrooms had sufficient supply of hand soap and paper products. At 10:29 a.m., the LPA observed hot water to be measured at 106.3 and 105.4-degree Fahrenheit.

GARAGE: At 10:34 a.m., the LPA observed the garage which is detached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible. The garage also has extra supplies such as paper products and food.

OUTDOOR SPACE: At 10:37 a.m., the LPA observed the backyard, which has a covered outdoor area for client use. The facility has a two side gates with latches for emergency exits. At 10:45 a.m., the LPA observed a client watering the plants.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a 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’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2022
LIC809 (FAS) - (06/04)
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