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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 03/17/2022
Date Signed: 03/22/2022 09:53:50 AM

Document Has Been Signed on 03/22/2022 09:53 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:KESHER OLAMFACILITY NUMBER:
565802457
ADMINISTRATOR:HERSHKOVITZ, CAMIFACILITY TYPE:
735
ADDRESS:4234 HITCH BLVDTELEPHONE:
(805) 306-0606
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 4CENSUS: 4DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Cami HershkovitzTIME COMPLETED:
02:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA met with Administrator Cami Hershkovitz.

During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted. LPA observed the fire extinguishers fully charged. LPA observed hot water temperature at 116.6 degrees F. in resident bathroom. There is an adequate amount of perishable food. PPE supplies were observed. First Aid kit is complete. The smoke alarms and carbon monoxide detector were tested and were operable. Outdoor area toured- passageways are free of obstruction.

During facility tour at 12:02 pm with Administrator LPA did not observe a sufficient supply of nonperishable fruit as the facility had 2 large and 3 small cans of fruit.

During facility tour at 12:05 pm with Administrator LPA observed cannabis tincture CBD 250 mg THC 125 mg accessible to clients.

During facility tour at 12:17 pm with Administrator LPA observed a door leading to a hallway with 3 room additions which is not on the facility sketch. Administrator stated that they did get building permits for room additions.

Continued on 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: KESHER OLAM
FACILITY NUMBER: 565802457
VISIT DATE: 03/17/2022
NARRATIVE
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 During facility tour at 12:33 pm with Administrator LPA observed insulating foam sealant, synthetic spray lubricant, paint and primer in a tote on the side of the house accessible to the clients.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/22/2022 09:53 AM - It Cannot Be Edited


Created By: Joann Rosales On 03/17/2022 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KESHER OLAM
FACILITY NUMBER: 565802457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as LPA did not observe a sufficient supply of nonperishable fruit which poses a potential health and personal rights risk to persons in care.
POC Due Date: 03/23/2022
Plan of Correction
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Administrator stated that they will provide documentation of a one week supply of nonperishable fruit to CCL by 3/23/22.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/22/2022 09:53 AM - It Cannot Be Edited


Created By: Joann Rosales On 03/17/2022 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KESHER OLAM
FACILITY NUMBER: 565802457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above as cannabis tincture, insulating foam sealant, synthetic spray lubricant, paint and primer were observed accessible to clients which poses an immediate health risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Administrator placed cannabis tincture in a locked medication cabinet during facility visit. Administrator stated that they will review and comply with the regulation and provide documentation of insulating foam sealant, synthetic spray lubricant, paint and primer in an inaccessible location to CCL by 3/18/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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Document Has Been Signed on 03/22/2022 09:54 AM - It Cannot Be Edited


Created By: Joann Rosales On 03/17/2022 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KESHER OLAM
FACILITY NUMBER: 565802457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80086(a)
Alterations to Existing Building or New Facilities.

Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above as the licensee added 3 additional rooms to the facility which poses a potential safety risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Administrator stated that they will provide documentation of an updated facility sketch and building permit to CCL by 3/25/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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