197608655-11-7-2022-29-AS-ECAS-CKXQFH-20221107110759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608655
Report Date: 11/07/2022
Date Signed: 11/07/2022 11:08:59 AM

Document Has Been Signed on 11/07/2022 11:08 AM - 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. 6		FACILITY NUMBER:	197608655
ADMINISTRATOR:	DINA VETCHTEIN		FACILITY TYPE:	740
ADDRESS:	23540 BURBANK BLVD.		TELEPHONE:	(818) 963-8360
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	11/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Doris Almario		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA’s) Elsie Campos arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff at 9:30 a.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Doris Almario at 9:50 a.m., to ensure there are no health and safety hazards.

BEDROOMS: There are (5) five bedrooms designated for resident use and (2) two bedrooms designated for staff use. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Hand-washing signs where identified in all restrooms. Restroom hot water measured between 112.4 and 117.6 degrees Fahrenheit between 9:58 a.m. and 10:08 a.m.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, medications, and chemicals were locked and inaccessible. Kitchen sink hot water measured 115.3 degrees Fahrenheit at 10:32 a.m.

COMMON SPACES: The common spaces included the living room and dining area. The LPA observed cameras in all common spaces and a screened fireplace in the living room. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, all were tested at 10:37 a.m. and observed to be operational. The fire extinguisher was observed to be full and last bought on 10/18/22. The LPA observed required postings on the wall of the living room. Flooring was checked for cleanliness and appeared in good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The laundry is located in a hallway closet.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SHALOM ELDERLY CARE, INC. 6	FACILITY NUMBER: 197608655
	VISIT DATE: 11/07/2022

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BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. There is a locked storage shed in the backyard containing cleaning supplies and gardening supplies.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Doris Almario regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. The facility has a 30-day supply of Personal Protection Equipment (PPE). 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 facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

This facility has records of staff and resident vaccinations. The facility has previously managed COVID-19 active and the facility complied with all requirements set forth by the local health department and licensing. The facility has stayed up to date regarding guidelines around visitation and vaccine requirements. The policies and procedure pertaining to infection control were adequate.

No deficiencies observed at this time. Exit interview conducted. A copy of the report was provided by email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC809 (FAS) - (06/04)

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