197608655-11-18-2023-29-AS-SURA-CXQ3AX-20231118170526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608655
Report Date: 11/18/2023
Date Signed: 11/18/2023 05:06:28 PM

Document Has Been Signed on 11/18/2023 05:06 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. 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: 5	DATE:	11/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Doris Almario		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with the Administrator Doris Almario at 12:20 p.m. 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.

COMMON SPACES: The common spaces included the living room and dining area. The LPA observed 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 and observed to be operational. The fire extinguisher was observed to be full and last bought on 10/15/2023. The LPA observed required postings on the wall of the living room. 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. The seven day supply of water and non-perishable food is located in a closet by the main entrance.

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.

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. Linen closet was observed to have a sufficient supply of linens and blankets.

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 were identified in all restrooms.

Continues on LIC 809...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

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. 6	FACILITY NUMBER: 197608655
	VISIT DATE: 11/18/2023

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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 supplies and gardening supplies. The passage ways were free of clutter.

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 2:00 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 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
- Liabiity Insurance

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: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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