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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 02/28/2023
Date Signed: 02/28/2023 04:55:22 PM

Document Has Been Signed on 02/28/2023 04:55 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:
02/28/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Cami HershkovitzTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual with focus on Infection Control. The last annual conducted at this facility was on 03/17/2022. LPA me with the Administrator, Cami Hershkovitz and the reason for the visit was explained. Entrance Interview.

The LPA along with the Administrator began the physical plant tour of the common areas, kitchen area, client bedrooms, client bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The LPA observed two (2) client bathrooms for hot water temperature; the first bathroom measured at 111.2 degrees Fahrenheit at 3:15 pm; and the second bathroom measured 107.8 degrees Fahrenheit at 3:20 pm. LPA observed two (2) refrigerators and one (1) freezer with an adequate amount of perishable and non-perishable food. Knives and sharps were observed in a locked drawer next to the oven. The kitchen sink was measured for hot water temperature and it measured at 109.4 degrees Fahrenheit at 3:11 pm. LPA observed fire extinguisher to be fully charged. At 3:22 pm, the smoke detectors and carbon monoxide detectors were tested and operable. LPA observed medications and first aid kits in a locked closet by the entrance. LPA observed Emergency food and water supply. The living areas and dining areas are clean and properly furnished. LPA observed cameras in all common areas. The facility was maintained at 68 degrees Fahrenheit at the time of visit. LPA observed outdoor grounds with clear passageways with no obstructions for emergency use. No bodies of water observed at the time of visit.

Report Continued on LIC 809C ...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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Document Has Been Signed on 02/28/2023 04:55 PM - It Cannot Be Edited


Created By: Martha Arroyo On 02/28/2023 at 04:34 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: 02/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as the staff bedroom window is broken, which posesd a potential safety risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Administrator stated that they will have the bedroom window fixed and provide photos/documentation to CCL by 03/10/2023.
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023


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: 02/28/2023
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Report Continued from LIC 809...

At 3:24 pm, LPA observed the staff bedroom window broken. Administrator stated window was accidentally broken with a ball.

During today's visit, the LPA spoke with the Administrator regarding the facility's infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVlD-19. All staff are fully vaccinated and boosted. No identified staffing concerns at the time of visit.

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 report and appeal rights were reviewed and issued to the Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
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