197609959-5-19-2022-29-AS-ECAS-CEJVWS-20220518164825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609959
Report Date: 05/18/2022
Date Signed: 05/19/2022 08:20:16 AM

Document Has Been Signed on 05/19/2022 08:20 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:	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: 6	DATE:	05/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Izhak Illouz		TIME COMPLETED:	04:55 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) 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 Administrator Izhak Illouz at 3:00 p.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Izhak Illouz and assistant Arlene Ceballos at 3:10 p.m., to ensure there are no health and safety hazards.

BEDROOMS: There are (6) six bedrooms designated for resident use and (1) one bedroom designated for staff use. Bedroom #3 Bedroom #4 and Bedroom #5 have a direct exit to the exterior. 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. The LPA observed accessible cleanser, over-the-counter topical medications and disinfectant in Bathroom #4. Restroom hot water measured between 109.7 and 116.2 degrees Fahrenheit between 3:20 p.m. and 3:28 p.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 118.2 degrees Fahrenheit at 3:10 p.m.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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 5

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: WALNUT GARDEN TOO	FACILITY NUMBER: 197609959
	VISIT DATE: 05/18/2022

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

COMMON SPACES: The common spaces included the living room and dining area and open laundry 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, there is a Carbon Monoxide detector installed at the facility. The LPA tested the fire alarm system at 3:30 p.m. and observed the system to be operating at the time of the visit. The fire extinguisher was observed to be full and last serviced on 11/1/21. The LPA observed required postings on the wall at the entrance. At 3:30 p.m. the LPA observed disinfecting wipes accessible. 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.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were two water fountains noted. Both fountains are surrounded with plants and lawn ornaments which make the fountains inaccessible. The LPA observed a storage unit containing additional incontinent supplies, personal protective equipment, and seasonal decorations.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Izhak Illouz 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 sufficient amount of Personal Protective 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.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via Email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 05/19/2022 08:20 AM - It Cannot Be Edited

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: WALNUT GARDEN TOO	FACILITY NUMBER: 197609959
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as there were accessible ointments and incontient wash on the bathroom counter top and accessible disenfectant under the bathroom sink and additonally accessible clorox disinfectant wipes at the entrance which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/18/2022
	Plan of Correction
1 2 3 4	The administrator agreed to do the followig: 1. Secure all items. POC cleared at the time of the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5