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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608653
Report Date:
10/18/2022
Date Signed:
10/18/2022 12:37:21 PM
Document Has Been Signed on
10/18/2022 12:37 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. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
SHALOM ELDERLY CARE, INC. 4
FACILITY NUMBER:
197608653
ADMINISTRATOR:
ALMARIO, DORIS
FACILITY TYPE:
740
ADDRESS:
5900 RUDNICK AVENUE
TELEPHONE:
(818) 703-1094
CITY:
WOODLAND HILLS
STATE:
CA
ZIP CODE:
91367
CAPACITY:
6
CENSUS:
6
DATE:
10/18/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Doris Almario
TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. The LPA met with Administrator Doris Almario and explained the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.
KITCHEN
: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. A carton containing 5 dozen eggs was found stored in a kitchen cabinet. Eggs are to remain refrigerated per the food safety guideline label indicated on the front of the egg carton. Administrator indicated the eggs had been bought on Sunday. Eggs were appeared unused, the carton was complete and sealed at the time of the visit. Administrator was reminded to ensure that labels are read appropriately for food storage requirements.
BEDROOMS
: The facility has six single-occupancy resident rooms and two staff rooms all which were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted.
RESTROOMS
: Five out of six resident rooms have an en suite restroom and there are two common restrooms, one located in the hallway and the other located in the laundry room. Restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 10:55 a.m. and 11:08 a.m., water temperatures measured between 103.6 F and 113.5 F. Restrooms were fully stocked. Hand-washing signs were observed.
COMMON SPACES
: Smoke detectors and common monoxide detector were operable at the time of the visit. Fire extinguishers were fully charged however last purchased on 3/31/2021 and in need of service or replacement. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. No bodies of water noted. The LPA observed one dented window screen and multiple windows with spiderwebs and debris. Administrator was reminded to ensure that windows are cleaned regularly. Upon LPA’s arrival it was determined that Staff #1 (S1) was not associated to the facility. The Administrator indicated that S1 was associated to a partner facility however had not had clearance transferred to this facility.
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2022
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
6
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:
SHALOM ELDERLY CARE, INC. 4
FACILITY NUMBER:
197608653
VISIT DATE:
10/18/2022
NARRATIVE
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INFECTION CONTROL
: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. Staff continue to document temperatures of staff and residents on a daily basis. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation and vaccine requirements. The facility recently managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility's procedures as it pertains to infection control are adequate.
The following deficiencies were observed (See LIC809-D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2022
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
10/18/2022 12:37 PM
- It Cannot Be Edited
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:
SHALOM ELDERLY CARE, INC. 4
FACILITY NUMBER:
197608653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as when LPA arrived at the facility Staff #1 (S1) was working and has been working at the faiclity since June and associated to a partner facility, but S1's criminal background clearance was not transferred to this facility prior to working with residents, which poses an immediate safety risk to persons in care.
POC Due Date:
10/18/2022
Plan of Correction
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The Administrator agreed to do the following:
1.Will provide LPA a copy of S1's LIC 508 and a photo ID during today's visit and LPA will transfer S1's criminal record clearance. Plan of correction met at the time of the visit. Civil Penalties assesed.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2022
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
10/18/2022 12:37 PM
- It Cannot Be Edited
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:
SHALOM ELDERLY CARE, INC. 4
FACILITY NUMBER:
197608653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as one window screen was observed to be dented allowing for insects to enter if window is left open additioanlty window screens were observed to have spider webs and debris which poses a potential health, and safety risk to persons in care.
POC Due Date:
10/28/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Clean all window screens and provide proof to CCL no later than 10/28/2022
2. Repair dented window screen and provide proof to CCL no later than 10/28/2022.
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, licensee failed to maintain an appropriate fire extinguisher as the fire extinguisher was last serviced 3/31/2021, which poses a potential health and safety risk to residents in care.
POC Due Date:
10/21/2022
Plan of Correction
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The Administrator has agreed to do the following:
1. Have the current fire extinguisher serviced or purchase a new one. Submit proof to CCL by 10/21/2022.
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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2022
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
10/18/2022 12:37 PM
- It Cannot Be Edited
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:
SHALOM ELDERLY CARE, INC. 4
FACILITY NUMBER:
197608653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/18/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as the LPA observed a carton of 5 dozen eggs to be stored in a kitchen cabinet. Eggs had a label indicating that they are to remain refrigerated at or below 45 degrees F to prevent illness from bacteria which poses a potential health and safety risk to persons in care.
POC Due Date:
10/21/2022
Plan of Correction
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The administrator agreed to do the following:
1. Dispose the eggs and replace and priovide proof to CCL no later than 10/21/2022.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Elsie Campos
TELEPHONE:
(747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2022
LIC809
(FAS) - (06/04)
Page:
6
of
6