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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 03/27/2026
Date Signed: 03/27/2026 05:07:24 PM

Document Has Been Signed on 03/27/2026 05:07 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:		SUSANA MIXFACILITY TYPE:
735
ADDRESS:4234 HITCH BLVDTELEPHONE:
(805) 306-0606
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 8CENSUS: 4DATE:
03/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Cami Hershkovitz, Licensee & Susan Mix, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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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 and 4-i home as of 02/01/2026. Accessory Dwelling Unit (ADU) in the back census is three (3) clients and the front main house census is one (1). Last disaster drill was completed 1/2026.

At approximately 10:45 a.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.

BEDROOMS: There are four (4) client bedrooms in the main house and four (4) client bedrooms in the Accessory Dwelling Unit (ADU) in the back. 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 and one (1) guest/common restroom in the main house; and two (2) client restrooms in the back ADU. Restrooms were observed clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with liquid hand soap/bar soap for individual use and paper towels; and individual towels and washcloths for clients use (not shared). The hot water temperature was measured in bathrooms used by clients which measured between 117.4-120 degrees Fahrenheit.

COMMON AREAS: Living room and dining room furniture was observed to be in good condition in the main house. Living room and furniture in the ADU also observed in good condition. The facility maintained a comfortable temperature in both units. There is a working telephone on premises. Smoke and carbon monoxide detectors tested functioned properly. (Continue to LIC809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 03/27/2026
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KITCHEN: Kitchen appliances in both units appeared clean and in working condition at the time of the visit. Non-perishable food supply for seven (7) days and perishable food supply for two (2) days observed sufficient for clients; Refrigerator and dry food pantry were checked for proper labeling. Food labels observed with dates clearly marked. Knives and sharps observed locked in the drawer/cabinet.
Fire extinguisher observed serviced 4/22/2025 and 3/1/2026.

LAUNDRY ROOM: There are separate washer and dryer on premises. One set is located in the main house and another in the back of the ADU. 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.

RECORDS: Records review began at approximately 11:45a.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. LPA reviewed P&I monies for all clients with the Administrator and Licensee. No discrepancies found. Medication review began at approximately 1p.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 Medication Administration Record (MAR); medication expiration dates are not logged on the MAR. Discussion held regarding use of MAR verses Centrally Stored Medication Record (CSMR). Administrator acknowledged understanding that if the medications are not recorded on the CSMR then the MAR should included all the information from the CSMR log. First aid kit observed complete with manual.

At approximately 2pm, our (4) personnel records including the current Administrator’s file was reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All personnel records observed complete with required records and training.

All clients and two staff were interviewed during today's visit from approximately 2:45pm-3:30pm.


There were no health and safety concerns observed during today’s visit. Exit interview conducted and copy of the report provided.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC809 (FAS) - (06/04)
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