198320323-10-25-2022-11-AS-TAGD-CKJNBW-20221025101950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320323
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:20:06 AM

Document Has Been Signed on 10/25/2022 10:20 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BEIT SHALOM		FACILITY NUMBER:	198320323
ADMINISTRATOR:	NAHUM, EILAT		FACILITY TYPE:	740
ADDRESS:	3121 CASTLE HEIGHTS AVE		TELEPHONE:	(310) 309-0405
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS: 0	DATE:	10/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	NAHUM, EILAT		TIME COMPLETED:	10:45 AM

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 Analysts (LPA) Troy Agard and Mario Leon conducted an announced visit to the above facility for the purpose of a pre-licensing evaluation. LPAs met with Licensee, Eilat Nahum and explained the purpose of the visit. During the inspection LPA toured the inside and outside of the facility and verified the address of the location. An application was submitted to Community Care Licensing Division (CCLD) on 09/01/2022 for an initial application for a Residential Facility for the Elderly. The total requested capacity is for 6 clients. Facility has a fire clearance dated on 07/29/2022 for, 5 non-ambulatory and 1 bedridden. Structure: Facility is a 1-story house located in a residential neighborhood. The facility has 6 resident-bedrooms, (all rooms are single occupancy). Upon entry, there is a foyer, kitchen to the left, living room, and dining room to the right. Through the hallway on the right is bedroom #1, a bathroom, storage and bedroom #3. On the right is 1 bathroom, bedroom #2 and #4, laundry room, bedroom #5, #6 and an additional bathroom. There is a 1-car garage, with a long driveway. There is a large backyard with a sitting area adjacent to the house. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA observed some hazards that were removed during visit. LPA did not observe a hazard such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms: All 6 residents bedrooms have a chair, nightstand, over-head lighting, dressers and/or closets. The closets and drawers comply with the requirement of 8 cubic feet of space. Office: Facility has a large storage space that will double as an office. That space is located between bedroom #1 and #3. Staff records and client records will be maintained in a locked cabinet in the office. cont. on 809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM	FACILITY NUMBER: 198320323
	VISIT DATE: 10/25/2022

NARRATIVE

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Bathrooms: Facility has 3 bathrooms. All bathrooms were observed to have a working toilet, and wash basin. All stand up showers and or bathtubs were observed in working order.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash cloths where observed stored in the hallway storage. Facility provides hygiene supplies to residents and LPA observed an adequate supply.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a dedicated landline was observed at the facility. Line was called by LPA and it is operational. Emergency Disaster Plan and "See something, say something, Let Us Know" was observed posted in foyer. LPA observed 2 fully charged fire extinguishers throughout the facility. One in the kitchen and one in the hallway.

Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and observed them to be brand new. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet. Food supply was adequately stored in kitchen refrigerator, cabinets and pantry.

Smoke Detectors: Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Detectors are not connected to any security alarm systems which will notify the fire department in the event of a fire. Facility will be required to call emergency services in the event of an emergency.

Appliances: Stove burners, oven, microwave, washer, and dryer are in working order. Laundry room is locked and accessible to staff only. There are 2 large refrigerators in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Toxins: Locked/stored in kitchen cabinet.

Medications, First-Aid Kit & Book: Area for medication storage is in a cabinet in the kitchen. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to residents.

Cont. on 809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM	FACILITY NUMBER: 198320323
	VISIT DATE: 10/25/2022

NARRATIVE

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Residents & Staff Files: Records of clients will be stored in storage/office.

Reading Material, Games, Equipment & Materials: The facility has recreational materials for the resident’s use.

Pool/Jacuzzi & Pets: LPA did not observe a pool or jacuzzi on facility grounds. No pets observed.

Fire clearance: Fire Clearance was approved on 07/29/2022 for 5 non-ambulatory and 1 bedridden. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits.

Component III: Conducted at the Pre-Licensing visit, on 10/25/2022 at BEIT SHALOM. Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection, no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC809 (FAS) - (06/04)

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