565802457-6-6-2022-29-AS-JROS-CF5SD6-20220606134638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 05/31/2022
Date Signed: 06/06/2022 01:47:00 PM

Document Has Been Signed on 06/06/2022 01:47 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 OLAM		FACILITY NUMBER:	565802457
ADMINISTRATOR:	HERSHKOVITZ, CAMI		FACILITY TYPE:	735
ADDRESS:	4234 HITCH BLVD		TELEPHONE:	(805) 306-0606
CITY:	MOORPARK	STATE: CA	ZIP CODE:	93021
CAPACITY: 4		CENSUS: 3	DATE:	05/31/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Cami Hershkovitz		TIME COMPLETED:	11:50 AM

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A virtual Informal Conference was conducted today. The purpose of this Informal Conference is to discuss building permits for the room addition, fire clearance, inspection authority for (ADU) Accessory Dwelling Unit, Staffing, and infection control.

In attendance included Licensing Program Manager (LPM) Kristin Heffernan, Licensing Program Analyst (LPA) JoAnn Rosales, (TCRC) Tri-Counties Regional Center (QAM) Quality Assurance Manager Freddie Garcia, and Administrator Cami Hershkovitz.

LPM Heffernan discussed the importance of mask wearing and that staff should be masked while in the facility. LPM stated that it is optional for the clients. Administrator stated that they were not masking in the beginning until they had an outbreak. Administrator stated that the clients will not wear the masks. LPM stated that the masking mandate is still in effect for all of our licensed facilities. LPM stated that they will send the Administrator and email providing the information for the (PIN) Provider Information Notice pertaining to the masking mandate.

LPM discussed an issue with Code Enforcement about an ADU. LPM stated that LPA was informed that it was not approved at the time. Administrator stated that they are not living in an ADU and that the ADU was not a part of the conversation. LPM stated that whenever there is an alteration to a facility (CCL) Community Care Licensing requires an updated facility sketch and an inspection from the Fire Inspector.

LPM discussed the staffing situation. Administrator stated that they had trouble staffing for many months. Administrator stated that they have placed professional ads and had hired 1 person who did not show up after being fingerprinted. Administrator stated that they recently hired a new staff which was a referral. LPM recommended Day Program staff. Administrator stated that they did reach out to local Adult Day

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SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: 05/31/2022

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Programs. LPM stated that CCL also has an (HCO) Home Care Organization list which they can email to the Administrator.

Administrator stated that they have video cameras in the living room, kitchen and in their office. Administrator stated that they cannot see in the bedrooms with the camera. Administrator stated that the video cameras were turned off but they did not agree with turning them off. Administrator stated that they also have the RING at the door which does have a recording system. Administrator stated that it is just a common RING that most people have and it was not meant for anything else. LPM advised Administrator that as it had been mentioned to them before that they are still staffing up the RING and will get back with them when they receive an answer. LPM advised Administrator to add an addendum to their Plan of Operation addressing all the points as noted in LPA's prior email to them as well as updating their Admission Agreement with residents so that they know about the cameras. Administrator stated that the residents families are aware of the cameras.

TCRC QAM wanted to clarify Administrator stating they their family member was living with them in the back. Administrator stated that their family member lives with them in the addition to the property.

TCRC QAM wanted to clarify the use of the ALEXA. Administrator stated that it is used mostly for reminders as it will say don't forget to feed the cat. Administrator stated that it is also used an alarm reminding clients to go to program. Administrator stated that it is not used for keeping an eye on the clients. Administrator stated that it also can be used by clients to call the Administrator. Administrator stated that the clients have cell phone to call them and they can also knock on their door. Administrator stated that they can also use it for music.

TCRC QAM wanted to discuss the supervision of the Administrators family member at night time. TCRC QAM stated that the Administrator has indicated that the addition has a separate address and is separate from the licensed facility which would mean that the residents are not being supervised while the Administrator is in the addition during the night. LPM stated to the Administrator that when CCL license a facility they license the whole parcel. LPM stated that CCL sees the room addition as a staff room. Administrator stated that Marco

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SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: 05/31/2022

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Hershkovitz is not working at the facility, but lives on the property and is only there to help with their family member. Administrator stated that Mr. Hershkovitz have the ability to be there if there was an emergency.

LPM discussed the new PIN 22-13-ASC that came out regarding the new requirement for the infection control plan. LPM stated that it now supersedes the Mitigation Plan and it is due 6/30/22.

Exit interview conducted and copy of today's report was emailed to the Administrator.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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