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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608654
Report Date: 11/19/2025
Date Signed: 11/19/2025 01:18:55 PM

Document Has Been Signed on 11/19/2025 01:18 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. 5FACILITY NUMBER:
197608654
ADMINISTRATOR/
DIRECTOR:		DINA VETCHTEINFACILITY TYPE:
740
ADDRESS:5912 RUDNICK AVENUETELEPHONE:
(818) 703-0159
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 5DATE:
11/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Doris AlmarioTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived unannounced to conduct a required annual visit at 10:08AM. LPA met with staff, Administrator Doris Almario who arrived shortly thereafter, and Licensee Dina Vetchtein who arrived at 10:32AM. 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 10:16AM. Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility had 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 seven (7) bedrooms total of which four (4) are single-occupancy resident rooms, one (1) is a shared resident room, one (1) is currently rented as a private resident living room, and one (1) is a staff room. All bedrooms were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear, no obstructions were noted. Staff room was observed locked.

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/visitor restroom located by the laundry room near the kitchen. The restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in resident bathrooms and were between 108.3-119.3 degrees F, which is within the required range. Report Continued on LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/19/2025
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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. Smoke detector(s) and carbon monoxide detector were tested at 10:36AM and were operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last purchased on 09/18/2025. LPA observed required postings throughout the common areas. Hallways contained supply closets with extra linens and emergency food and water supply. All auditory exit devices in common areas and bedrooms were functional and operating at the time of the visit.

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

RECORD REVIEW: Beginning at 10:40AM, LPA reviewed five (5) out of five (5) 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 12PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet in the kitchen area. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law.

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 09/05/2025.

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
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