197608654-11-14-2024-29-AS-ABAN-DAZSVT-20241114131316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608654
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:13:56 PM

Document Has Been Signed on 11/14/2024 01:13 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. 5		FACILITY NUMBER:	197608654
ADMINISTRATOR/ DIRECTOR:	DINA VETCHTEIN		FACILITY TYPE:	740
ADDRESS:	5912 RUDNICK AVENUE		TELEPHONE:	(818) 703-0159
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Doris Almario		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived unannounced to conduct a required annual visit at 10:40AM. LPA met with staff. Administrator Doris Almario arrived at 10:53AM and Licensee Dina Vetchtein arrived at 11:08AM. Entrance interview conducted.

LPA and 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. The following was observed:

KITCHEN/LAUNDRY/GARAGE: LPA toured the kitchen at 10:53AM. 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 garage attached to the kitchen is kept locked and contains two (2) additional freezers and extra supplies. The laundry room by the kitchen contained locked and inaccessible cleaning supplies, disinfectants, and detergents.

BEDROOMS: The facility has four (4) single-occupancy resident rooms, one (1) double-occupancy resident room, one (1) single-occupancy resident room currently rented as a private resident living room, and one (1) staff room. All bedrooms were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted.

RESTROOMS: The facility has seven (7) restrooms. Five (5) out of six (6) resident bedrooms have an attached restroom, there is one (1) private restroom in the hallway, and one (1) staff restroom located by the laundry room near the kitchen. The restrooms were clean and sanitary with grab bars and slip-resistant surfaces. Between 10:59AM – 11:03AM, LPA measured hot water temperatures in resident restrooms to be between 105.2 degrees F – 113.3 degrees F, which is within the required range.

Report continued on LIC 809-C.

Kristin Heffernan	TELEPHONE: (818) 596-4493
Angela Barutyan	TELEPHONE: 747-922-1234
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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. 5	FACILITY NUMBER: 197608654
	VISIT DATE: 11/14/2024

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COMMON AREAS: These include the living room and dining area. All common areas were observed to be in good condition. There is a screened and inaccessible fireplace in the living room. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were tested at 11:14AM and were operational at the time of the visit. The fire extinguisher in the kitchen was fully charged and last purchased on 10/21/2024. LPA observed required postings throughout the common areas. Hallways contained supply closets with extra linens and emergency water supply.

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.

RECORD REVIEW: Beginning at 11:20AM, LPA reviewed six (6) out of six (6) resident and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order.

MEDICATION REVIEW: At 12:33AM, LPA reviewed medications for three (3) residents. Medications are centrally stored and locked in a cabinet in the kitchen area. Medications are labeled and checked for expiration dates. At 12:37AM, LPA observed three (3) medications for Resident #1 (R1) that were missing start dates on the centrally stored medication and destruction record. Two (2) out of three (3) of the medications had start dates written on the medication bottle. For the third medication, staff counted the number of pills to determine the start date. LPA observed the medications for the two (2) other residents to be properly documented.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 09/10/2024.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 01:13 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SHALOM ELDERLY CARE, INC. 5	FACILITY NUMBER: 197608654
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above as three (3) medications for Resident #1 were missing start dates on the centrally stored medication and destruction record which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	Staff counted medication pills and inputted the correct start dates on the centrally stored medication and destruction record. POC cleared during visit.

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.

Kristin Heffernan	TELEPHONE: (818) 596-4493
Angela Barutyan	TELEPHONE: 747-922-1234
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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