197608309-6-30-2023-29-AS-CYEE-CT9VCS-20230629161936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608309
Report Date: 06/29/2023
Date Signed: 06/30/2023 07:18:59 AM

Document Has Been Signed on 06/30/2023 07:18 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ETTA ISRAEL CENTER #4		FACILITY NUMBER:	197608309
ADMINISTRATOR:	HEIDI SCHOFIELD		FACILITY TYPE:	735
ADDRESS:	6101 BLUEBELL		TELEPHONE:	(818) 980-1709
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	06/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Heidi Schofield, Administrator		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) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection tool. LPA Yee was let into the home by Emilio Briseno, Staff. Heidi Schofield, Administrator arrived a little later to conduct the visit. Also participating in today's visit was Giovanna Montano, Supervisor. The facility is a single storey home consisting of a front room, dining room, living room, kitchen, laundry room, 4 resident bedrooms, a common bathroom, a private bathroom and a detached garage. The following were observed on today's visit: The living room, dining room and front room had the appropriate furniture for the approved capacity The kitchen has an operable stove, dishwasher and refrigerator. Sufficient perishable and non-perishable foods were observed. Cleaning supplies are stored in a locked cabinet under the kitchen sink, knives are locked in a cabinet in the front room and laundry detergent are locked in a front closet.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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 06/30/2023 07:19 AM - It Cannot Be Edited

Created By: Christine Yee On 06/29/2023 at 03:16 PM

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 #4	FACILITY NUMBER: 197608309
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 2 observation of the outside walkways, the walkway located on the right side of the faciity, it was observed to be uneven due to the cement was cracked and broken, creating holes, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2023
	Plan of Correction
1 2 3 4	The Licensee will ensure that the walkways on the faciity premises are well maintained. Licensee will have the walkway repaired and provide evidence of the repair by the POC date of 7/13/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Christine Yee

LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETTA ISRAEL CENTER #4	FACILITY NUMBER: 197608309
	VISIT DATE: 06/29/2023

NARRATIVE

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Medications are centrally stored in a cabinet located in the dining room.
all the resident bedrooms had the required furniture
lamps were observed in bedroom #2 and bedroom #3. There were no lamps in bedroom #1 and bedroom #4 but sufficient lighting was observed.
Appropriate linens were observed on client's beds and extra linens in the linen closet.
fire extinguishers were observed in the front room and laundry room. They were last inspected on 10/12/22.
the hardwired and interconnected smoke detectors were tested and were operational
The 2 carbon monoxide detector located in the living room and the hallway were tested and were operational
The water temperature was tested in the common bathroom and read 114.0 degrees Fahrenheit and the water tested in the private bathroom read 113.2 degrees Fahrenheit
The back and front yard were observed to be clean and well maintained except that the concrete walkway on the right side of the facility was cracked and broken up, creating an uneven surface and holes in the walkway.
Located in the backyard is a table and chairs for outside activities.

Deficiencies are cited under California Code of Regulations, Title 22, Division 6 Chapter 1.
Exit interview was conducted, Appeals Right discussed and a copy provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

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