198600051-5-18-2023-29-AS-AASO-CRXVY8-20230518165043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600051
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:51:35 PM

Document Has Been Signed on 05/18/2023 04:51 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ETTA ISRAEL CENTER ADULT RESIDENTIAL #2		FACILITY NUMBER:	198600051
ADMINISTRATOR:	HEIDI SCHOFIELD		FACILITY TYPE:	735
ADDRESS:	6053 ALCOVE		TELEPHONE:	(818) 358-3290
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 5	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Heidi Schofield		TIME COMPLETED:	05:00 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) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA met with staff and explained the reason for the visit. Administrator Heidi Schofield arrived shortly after. The LPA, with the guidance a staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: All client rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are six (6) total bedrooms for client use – all client rooms are private rooms. RESTROOMS: There are five (5) total bathrooms at the home. The client bathroom has a shower with non-skid materials. The toilet and shower have grab bars. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to client in care. In addition, restroom hot water measured under 120.0 degree F. KITCHEN: Kitchen knives are stored in a locked closet by the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0F) and the refrigerator was maintained at 40F. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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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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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #2	FACILITY NUMBER: 198600051
	VISIT DATE: 05/18/2023

NARRATIVE

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The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins
stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all
appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed. Hot water in kitchen was measured at 115.3 degrees Fahrenheit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. Fire extinguishers
were observed to be serviced within the last year. The facility smoke alarm system is hardwired and
operated normally at the time of visit. Medications were observed to be locked in a closet by the
kitchen and contained at least 30 days of worth of medication. The garage door is accessible within the home was observed locked, additionally the garage contained a locked cabinet for laundry supplies, emergency food supply and the overflow of medication. The backyard has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator Schofield regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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.

Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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