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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:05:21 PM

Document Has Been Signed on 05/17/2022 02:05 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:HERSHKOVITZ, CAMIFACILITY TYPE:
735
ADDRESS:4234 HITCH BLVDTELEPHONE:
(805) 306-0606
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 4CENSUS: 3DATE:
05/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Cami HershkovitzTIME COMPLETED:
02:04 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales and Tri Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett conducted a Case Management visit to follow up on incidents that occurred at the facility in October and December 2020 which was reported via email by the Administrator to their Service Coordinator. LPA met with Administrator Cami Hershkovitz. 1 Client was at Day Program, 1 client was at Post Secondary School and 1 client was with their family during the facility visit. Administrator stated that the clients were clear to leave the facility per Ventura County Public Health.

Upon arrival to the facility LPA observed video cameras in the common areas of the facility. Administrator stated that the cameras have been disconnected. LPA advised Administrator that they will need to update their Plan of Operation and Admission Agreement to include the use of video cameras in the common areas of the facility. LPA let Administrator know that they will need to submit the revised Plan of Operation and Admission Agreement to Community Care Licensing (CCL) for review and approval.

Interview with Administrator on 5/17/22 starting at 11:30 am revealed that there was only one incident that occurred in October 2020 with their family member who lives at the facility and client #1 (C1). Administrator stated that they do not recall the actual date that it occurred and it is not documented. Administrator stated that they were outside of the facility and were the only staff at the time when their family member ran toward C1 who was sitting in a chair at the dining room table. Administrator stated that C1 saw the family member coming towards them and they jumped up and backed off. Administrator stated that their family member was not attacking C1 and did not body slam C1 as indicated in their prior email to their Service Coordinator. Administrator stated that C1 never fell and was not touched by their family member. Administrator stated that their family member was not trying to attack C1 and continued to run out the front door. Administrator stated that their family member had a staff from CABA (Center for Applied Behavior Analysis) agency supervising

Continued on 809C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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: 05/17/2022
NARRATIVE
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them at the time of the incident. Administrator stated that when they reported the incident to their Service Coordinator they initially though C1 had fallen but after speaking with the CABA staff they found out that C1 did not fall.

Administrator stated that in November 2020 they do not recall the specific date and it was not documented anywhere C1 was outside hanging out and their family member ran into C1 and C1 fell into a wagon that was beside C1. Administrator stated that C1 did not sustain any injuries. Administrator stated that they were the only staff and were outside when the incident occurred. Administrator stated that their family member just got home from school and for some reason when the get off the bus they like to run around. Administrator stated that their family members staff from STS (Specialized Therapeutic Services) was there around 10 to 15 minutes after the incident occurred.

Administrator stated that during the incident that occurred on 12/5/2020 they were following their family member down the driveway and C2 was walking along the gravel towards the driveway. Staff #1 (S1) saw their family member run into C2. Administrator stated that they took C2 to the Hospital as they observed what they thought was too much blood on C2's head. Administrator stated that C2 was cleared by the Hospital with no damage to their scalp.

Administrator stated that they do not know if their family member intentionally ran into the clients as based on their diagnosis they are not able verbalize that to them. LPA asked Administrator the date of birth for their family member who lives at the facility and observed that the family member was 18 during the time of the incidents.

Based on the information provided during the investigation LPA determined that the Administrators family member is over 18 and is not currently associated to the facility.



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

Civil Penalties issued in the amount of $500.00.

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

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2022 02:05 PM - It Cannot Be Edited


Created By: Joann Rosales On 05/17/2022 at 01:42 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: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/18/2022
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance. (e)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
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Administrator stated that they will provide documentation of their family member being fingerprint cleared and associated to the facility by 5/18/22.
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Based on record review and interview with Administrator the licensee did not comply with the section cited above their family member is not fingerprint cleared and associated to the facility which poses an immediate safety and personal rights risk to persons in care.
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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: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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