195850486-5-3-2024-29-AS-EPEI-D4WQFS-20240503120826

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850486
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:08:59 PM

Document Has Been Signed on 05/03/2024 12:08 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WALNUT GARDEN IV		FACILITY NUMBER:	195850486
ADMINISTRATOR/ DIRECTOR:	ILLOUZ, IZHAK		FACILITY TYPE:	740
ADDRESS:	5128 CEDROS AVE		TELEPHONE:	(818) 855-1459
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY: 6		CENSUS: 6	DATE:	05/03/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Izhak Illouz		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Emily Peraldi conducted a pre-licensing visit to the above noted facility. At 10:30 a.m., the LPA met with applicant, Izhak Illouz. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver for six (6) has been requested. At 10:40 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and one (1) bedridden resident. The facility is one story. The facility has six (6) resident bedrooms. All resident bedrooms have a direct exit to the outside except bedroom #4 and #5. Bedridden resident is allowed in resident bedroom #1. All resident rooms are set up with beds, nightstands, lamps, chairs, chest of drawers and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed). Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is one (1) additional room used for staff. All rooms were free of odors. All window screens were clean and maintained in good repair. There are seven (7) bathrooms in the facility, and the bathroom located in one of the main hallways is designated for staff and guests. The resident bathrooms have a shower with non-skid materials/ mats. The toilet and shower have grab bars. The hot water temperature was tested in the bathroom and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records are stored in the office area. Medications are centrally stored in locked hallway closet. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN IV	FACILITY NUMBER: 195850486
	VISIT DATE: 05/03/2024

NARRATIVE

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Kitchen knives are stored in a locked kitchen drawer. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable and perishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area. Appliances in the kitchen were clean and all appeared functional. Laundry units and house cleaning supplies are stored inside the locked laundry room. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included but not limited to flashlights. The facility had emergency food and water supplies. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. At 11:15 a.m., the smoke detector and carbon monoxide detectors were tested and functioned properly. The facility has a central entry point for symptom screening and temperature checks for staff and visitors. There are hand sanitizers available throughout the facility.

The fire extinguishers throughout the facility were fully charged and last serviced on 02/06/2024. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored throughout the facility. Extra incontinence supplies and other supplies are located outside in the locked storage sheds. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility. The emergency telephone numbers are posted near the entrance of the facility. Other required postings are also posted near the entrance of the facility.

Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN IV	FACILITY NUMBER: 195850486
	VISIT DATE: 05/03/2024

NARRATIVE

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The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The property is gated. One side of the house is designated for an emergency exit. There are locked storage sheds in the back yard. There are no bodies of water on the premises at the present time.

Component III was conducted in conjunction with this pre-licensing visit.

No corrections required. Exit interview conducted. A copy of the report was issued.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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