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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609959
Report Date: 10/31/2023
Date Signed: 10/31/2023 05:47:39 PM


Document Has Been Signed on 10/31/2023 05:47 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:WALNUT GARDEN TOOFACILITY NUMBER:
197609959
ADMINISTRATOR:ILLOUZ, IZHAKFACILITY TYPE:
740
ADDRESS:12805 COLLINS STTELEPHONE:
(818) 509-7989
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:6CENSUS: 6DATE:
10/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Izhak Illouz, AdministratorTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to deliver the amended complaint reports LIC9099, LIC9099-C, LIC9099-D and :LIC421M - Immediate Civil Penalty Assessment - Immediate $500 and Repeat Violations. LPA Yee met with Izhak Ilouz, Administrator. and the reason for today's visit was explained.

The investigation for complaint #29-AS-20230721162950, received on 7/21/23, was conducted by LPA Angel Ascencio on 7/28/23. Based on LPA Ascencio's investigation, the allegation that the facility was operating over capacity was substantiated. The facility is licensed for 5 Non-Ambulatory and 1 bedridden resident based on the fire clearance approved by the fire department. The Licensee took on the 7th resident and placed them in a converted alternate dwelling unit(ADU) located at the same address as the facility. The ADU was not inspected by the fire department and a fire clearance was never obtained for the ADU to be used as a bedroom. On 7/28/23 the facility was cited for this deficiency under Title 22, Section 87468.2(a)(1) - Additional Personal Rights of Residents in Privately Operated Facilities (a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. The citation was corrected and cited under: Fire Clearance: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.


Exit interview was conducted with the Administrator, Appeals Rights discussed and a copy was given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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