197609959-5-27-2020-29-AS-BBAI-BPZPZ5-20200527114459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609959
Report Date: 05/27/2020
Date Signed: 05/27/2020 11:45:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME:	WALNUT GARDEN TOO		FACILITY NUMBER:	197609959
ADMINISTRATOR:	ILLOUZ, IZHAK		FACILITY TYPE:	740
ADDRESS:	12805 COLLINS ST		TELEPHONE:	(818) 509-7989
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 5	DATE:	05/27/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:28 AM
MET WITH:	Izhak Illouz		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi initiated a pre-licensing inspection today. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection was conducted telephonically at 10:30am with Izhak Illouz the facility administrator. This is a one story residence and will be licensed to serve (6) residents, with fire clearance approval for (5) non ambulatory and (1) bedridden resident. There are (6) bedrooms for residents and (1) bedroom for staff use only. The physical plant was toured inside and out with Administrator. LPA observed wired smoke and carbon monoxide detectors throughout the facility. (2) fire extinguishers located in the facility, both were fully charged and last inspected on 2-2020. All rooms are set up with beds, night stands, comfortable/appropriate chairs, chest of drawers and closet space. Lighting in the rooms appeared adequate at the time of the visit. All rooms have overhead lighting. Bathrooms are equipped with grab bars and non-skid materials. Hot water tested in the bathrooms measured between 105 - 107 degrees F. LPA observed an adequate supply of perishable and non-perishable foods in the fridge. Medications were stored in a locked pantry in the corner of the kitchen. Sharp objects and knives were stored in a locked drawer to the left of the kitchen sink. LPA observed a sufficient supply of non-perishable foods and dried goods stored in the pantry. Emergency food supply was stored in thislocation as well. LPA did not observe any cleaning supplies stored in the kitchen. At 10:45am LPA observed staff cleaning the kitchen. The supply of dishes was observed to be adequate at this time. Continued on 809-C

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: WALNUT GARDEN TOO	FACILITY NUMBER: 197609959
	VISIT DATE: 05/27/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 809

The common areas were appropriately furnished, and lighting was adequate at the time of the visit. At 10:50am LPA observed (2) resident sitting in living room watching television .

There is a covered porch area in the rear of the house with outdoor furniture. There were (2) storage units located in the backyard inaccessible to residents. LPA observed both to be inaccessible to residents. LPA observed painting supplies and cases of bottled water being stored. Exit passageways were clear of hazards and obstructions. At 11:00am LPA observed resident sitting outside on patio.

Licensee completed Comp III on March 10, 2020.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2