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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608859
Report Date: 04/01/2022
Date Signed: 04/01/2022 03:01:15 PM


Document Has Been Signed on 04/01/2022 03:01 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:EILAT'S MANORFACILITY NUMBER:
197608859
ADMINISTRATOR:MIRIAM RUDESFACILITY TYPE:
740
ADDRESS:1621 S. SHERBOURNE DRIVETELEPHONE:
(310) 273-3133
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 4DATE:
04/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eilat Nahum TIME COMPLETED:
03:15 PM
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On 04/01/2022 Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Ulysses Coronel conducted a Case Management - Health and Safety Check to the above facility and met with Eilat Nahum Administrator.

During today visit LPA and LPM conducted a tour of the facility and interviewed R1 who was a former resident of Beit Shalom #197608630.

No deficiencies were cited. A copy of this report was provided to Eilat Nahum, Licensee.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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