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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608523
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:29:59 PM

Document Has Been Signed on 10/13/2022 02:29 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:CALIFORNIA SENIOR OF SHERMAN OAKSFACILITY NUMBER:
197608523
ADMINISTRATOR:JEFFERSON REYESFACILITY TYPE:
740
ADDRESS:14802 MORRISON STREETTELEPHONE:
(818) 849-5525
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 6CENSUS: 5DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Heber AlcazarTIME COMPLETED:
02:36 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit and inspection of the facility. This inspection had an emphasis on infection control. The LPA met with staff Heber Alcazar, and explained the reason for the visit. The LPA also spoke with the Administrator Jefferson Reyes to explain the reason for the visit.

The LPA, and staff conducted a tour of the physical plant. Required postings were observed in entry and living room area. INFECTION CONTROL: Upon entry, the facility has a sign in book, thermometer to take temperature, and sanitizing gel. Infection Control signage was visible at entrance.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored knives were stored in a locked drawer at the time of the visit. Properly labeled medications and cleaning supplies were in stored in locked cabinets in the kitchen.

Bedrooms: There were five bedrooms designated for residents' use. Bedrooms were clean, properly furnished and had sufficient lighting. There were appropriate bedding and linens.

Bathrooms: There were two bathrooms designated for residents' use. Both bathrooms were clean, properly supplied and had functional fixtures. There is one staff bathroom, which needs to have the hand washing sign posted.

Common Areas: These included the living room and dining areas. The common areas appeared clean and were properly furnished.

Continues on LIC809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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: CALIFORNIA SENIOR OF SHERMAN OAKS
FACILITY NUMBER: 197608523
VISIT DATE: 10/13/2022
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Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area had furniture appropriate for outdoor use. The garage is a separate structure from the home, is used for storage, and is kept locked. The laundry is area is just off the kitchen, detergents are stored in a locked shelf in the laundry area.

The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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