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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 03/11/2025
Date Signed: 03/11/2025 06:57:59 PM

Document Has Been Signed on 03/11/2025 06:57 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:KESHER OLAMFACILITY NUMBER:
565802457
ADMINISTRATOR/
DIRECTOR:		MARKO HERSHKOVITZFACILITY TYPE:
735
ADDRESS:4234 HITCH BLVDTELEPHONE:
(805) 306-0606
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 8CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Cami HershkovitzTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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A required annual inspection was conducted today by Licensing Program Analysts (LPA) Zabel Chochian. Upon arrival, LPA was greeted at the door by licensee representative, Cami Hershkovitz and reason for the visit was stated. The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3-i home.
At approximately 12p.m., a physical plant tour of areas inside and outside was conducted to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Smoke and carbon monoxide detectors tested and were operable during todays visit. Fire extinguisher observed in the kitchen with service tag dated 4/2024.

BEDROOMS: There are four (4) client bedrooms. The LPA observed the client bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are two (2) client restrooms. Restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with liquid hand soap and paper towels; towels and washcloths are not shared. The hot water temperature was measured in bathroom used by clients which measured at 117.4 degrees Fahrenheit. COMMON AREAS: Living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. There is a working telephone on premises. KITCHEN: Kitchen appliances appeared clean and in working condition at the time of the visit. Non-perishable food supply observed sufficient for seven days; the supply of perishable food items observed insufficient during today's visit. Refrigerator and dry food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. Knives and sharps observed locked and inaccessible in the drawer. (Continue to LIC809c).

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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: 03/11/2025
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LAUNDRY ROOM: There is a washer and dryer on premises. The staff assist clients with all laundry needs. The LPA observed detergents and cleaning supplies locked and inaccessible to clients in care.
BACKYARD: The backyard has an area equipped with furniture for client use. Emergency exits and passageways were observed free of obstruction. No bodies of water noted at the time of the visit.

Accessory Dwelling Unit (ADU) in the back observed vacant during LPA's visit. Currently no clients residing in the ADU.

RECORDS: Records review began at approximately 1:30p.m.; four (4) client records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were complete; however, needs and services plans and client functional capabilities assessment forms were not signed. A technical advisory was issued. Four (4) personnel records including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff #4's health screening copy was not on file (TB copy is on file); a technical violation was issued.

MEDICATIONS: Medications review began at approximately 4p.m.; medications are centrally stored in a locked closet by the front entrance. All medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored record. No errors observed during the medication review.

The following deficiencies was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 06:57 PM - It Cannot Be Edited


Created By: Zabel Chochian On 03/11/2025 at 04:51 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: 03/11/2025

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 observation, the licensee did not comply with the section cited above. Perishable food supply was low (fresh fruits and vegatibles. This poses a potential health and personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Licensee agreed to purchase additional fresh fruits and vegatibles and submit a photo of the food items and reciept by POC date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Licensee cound not locate the facility's emergency/disaster plan during todays visit; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee agreed to complete a new plan using the departments form and submit a copy by POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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