197608653-11-8-2023-29-AS-SURA-CXE2DP-20231108161836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608653
Report Date: 11/08/2023
Date Signed: 11/08/2023 04:19:19 PM

Document Has Been Signed on 11/08/2023 04:19 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
WOODLAND HILLS N.ASC, 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:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Doris Almario		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual visit. The LPA met with Administrator Doris Almario and explained the reason for the visit.

The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 109.8 degrees Fahrenheit.

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 a restroom and there are two common restrooms, one located in the hallway and the other located by the laundry room. The restrooms were clean and sanitary with grab bars and non-skid surfaces. Water temperatures measured between 105.5- and 109.3-degrees Fahrenheit. Restrooms were fully stocked. Hand-washing signs were observed.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced on 10/13/2023. The LPA observed required postings throughout the common space. Cleaning supplies and disinfectants are kept in locked cabinets in the laundry room.

Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SHALOM ELDERLY CARE, INC. 4	FACILITY NUMBER: 197608653
	VISIT DATE: 11/08/2023

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted.

RECORDS: Records review began at 1:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 3:00 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors were observed during the medication review.

INFECTION CONTROL: The facility has 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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