198600051-5-30-2024-29-AS-KDUK-D5RULR-20240530154110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600051
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:41:23 PM

Document Has Been Signed on 05/30/2024 03:41 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/ DIRECTOR:	HEIDI SCHOFIELD		FACILITY TYPE:	735
ADDRESS:	6053 ALCOVE		TELEPHONE:	(818) 358-3290
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:23 PM
MET WITH:	Heidi Schofield		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:23 PM. The LPA initially met with house lead Xiomara Cruz. LPA explained the reason for today's visit. The Administrator was contacted via telephone and arrived shortly after the visit began. Entrance interview conducted.

The facility is vendored through North Los Angeles County Regional Center as a level 4g home.

Beginning at 12:35PM, the LPA, along with house lead toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

Smoke alarms and separate carbon monoxide detector were tested at 03:27PM and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 10/18/2023.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives are stored in a locked cabinet. Cleaning supplies are stored in a locked cabinet under the kitchen sink. Medications are stored in a separate locked kitchen cabinet.

LAUNDRY: The facility contains a laundry room adjacent to the facility kitchen. Laundry detergents are stored locked with other chemicals.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the common areas. The backyard patio contains a shaded area and is equipped with furniture for clients' use. Garage was observed to be locked and contained extra food, paper products and emergency supply.

BEDROOMS: The LPA observed 6 (six) private client bedrooms; 4 (four) are on the first floor and 2 (two) are upstairs. All client bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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: 05/30/2024

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CLIENT FILES/CASH RESOURCES: LPA reviewed 5 (five) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All 5 (five) of 5 (five) client files reviewed were complete and contained all documentation required.

MEDICATION REVIEW: LPA reviewed medications for 2 (two) clients. All medications reviewed were documented and stored in compliance with regulation.

STAFF FILES: LPA reviewed 5 (five) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. All 5 (five) staff files reviewed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted monthly, with the last drill conducted on 04/02/2024. Emergency disaster plan was observed to be complete and updated annually.

INTERVIEWS: During today's visit, LPA interviewed 2 (two) clients and 2 (two) staff.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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