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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802457
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:35:29 PM

Document Has Been Signed on 11/21/2024 02:35 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:		HERSHKOVITZ, CAMIFACILITY TYPE:
735
ADDRESS:4234 HITCH BLVDTELEPHONE:
(805) 306-0606
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 8CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Cami HershkovitzTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Martha Arroyo along with Tri-Counties Regional Center Quality Assurance Specialist (QAS), Liz Aced-Arnett conducted an unannounced case management – incident visit to the above facility. The purpose of today’s visit is to continue the investigation of a self-reported incident submitted to the department on 10/04/2024. LPA and QAS met with staff, Cami Hershkovitz and the reason for the visit was explained. Entrance interview.

The written incident report contained information regarding an incident from 10/03/2024 involving Resident #1 (R1), Resident #2 (R2), and Resident #3 (3) where R1 had a confrontation with R2 over a missing lock from a bathroom they both share, and over candy that R1 was accused of stealing and consuming that belong to all the residents to share. R1 was found to have lied about eating the candy when the candy wrappers were visible in R1’s trash that was near R1’s bedroom door, causing anger amongst the other residents, as R1 has a history of taking others property. R2 did proceed in a bully technique determined to get R1 to admit the taking of the lock and then teased R1 with the other residents of them eating gum portraying how sharing should look like. This ended up with R1 taking the 1st aggression by grabbing R2’s hair tightly and kicking R2 in the stomach bringing R2 to the floor, R3 was screaming and crying and sat on the floor to console R2 when R1 ran up and kicked R3 in the stomach. R1 then straddled R2 and began fist punching R2 in the head, ears, and neck areas, ripping off R2’s necklace leaving marks on R2’s ear and neck. Staff #1 (S1) attempted to part them while they were on the floor but was unable to. Staff #2 (S2) heard the screams from outside where S2 was at the moment, ran in and used their body with hands in the air parting them and was successful. S2 walked backwards directing R1 back to R1’s room away from the incident and requested R1 go their room to calm down.
Report Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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: 11/21/2024
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Report Continued from LIC 809...

R1 ran into the room to return with small objects trying to push S2, R1 threw the objects towards the other residents. R1 ran into their room to return with a bottle of perfume and started to spray, attempting to spray their faces as if it was mace but ended with it all over S2. During this whole episode there was cursing words with middle finger gestures, from all, with the exception R1 wished roommates to die comments in hostile anger. S1 went to R1 to check on R1 and try to be calm, but instead R1 attacked S1 by using fist to strike S1 and bite S1, but S1 managed to push R1 away, skin was not broken. Then R1 kicked S1 in the ribs hard, then sprayed perfume into S1’s face, as S1 then fled. S1 managed to retrieve perfume and it is currently locked up as it was used as a weapon. S2 pulled a chair and sat in the hallway for approximately 25 minutes until the staff shift changed at 6pm. Staff #3 (S3) arrived at 6pm and was quickly informed and took over, but all was calm at this point. S2 stayed on the property for a while to check in to be sure all was well. Once R1 calmed a bit, R1 was offered dinner in R1’s room along with R1’s medications, and then R1 showered and remained in R1’s room for the rest of the night.

During the initial visit on 10/22/2024, the LPA and QAS interviewed one staff at 9:50 a.m. On today’s visit, the LPA and QAS interviewed two (2) staff and one resident between 1:20 p.m. and 2:15 p.m. regarding the incident.

Information obtained during the course of the investigation, it was revealed that staff redirected resident’s during and after incident occurred to try and keep resident’s safe. No additional follow up is needed.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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