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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608630
Report Date: 06/21/2021
Date Signed: 06/21/2021 03:17:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BEIT SHALOMFACILITY NUMBER:
197608630
ADMINISTRATOR:MIRIAM RUDESFACILITY TYPE:
740
ADDRESS:8537 PICKFORD STREETTELEPHONE:
(310) 309-0405
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 5DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Naomi Leibov-CaregiverTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Naomi Leibov, Caregiver and the purpose of today’s visit was explained. The facility is licensed to serve residential care elderly 6 NON-AMBULATORY, OF WHICH 1 MAY BE BEDRIDDEN and HOSPICE WAIVER FOR 1.

There are currently (5) elderly residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 4 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor /outdoor activity area and laundry.

LPA and staff toured the physical plant with caregiver. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115F, 105F, 108F and 109.5 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

LIC9099-C is on the next page.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEIT SHALOM
FACILITY NUMBER: 197608630
VISIT DATE: 06/21/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Naomi, Caregiver.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC809 (FAS) - (06/04)
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