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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608655
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:17:38 PM

Document Has Been Signed on 11/19/2024 12:17 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:SHALOM ELDERLY CARE, INC. 6FACILITY NUMBER:
197608655
ADMINISTRATOR/
DIRECTOR:		DINA VETCHTEINFACILITY TYPE:
740
ADDRESS:23540 BURBANK BLVD.TELEPHONE:
(818) 963-8360
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:39 AM
MET WITH:Dina VetchteinTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived unannounced to conduct a required annual visit at 10:39AM. LPA met with staff. Licensee Dina Vetchtein and Administrator Doris Almario arrived at 10:49AM and reason for the visit was explained. Entrance interview conducted.

LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: LPA toured the kitchen at 10:43AM with staff. Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The facility has six (6) single-occupancy resident rooms and one (1) staff room, all of which were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. Staff room is kept locked and inaccessible.

RESTROOMS: The facility has seven (7) restrooms. Six (6) out of six (6) resident bedrooms have an attached restroom and there is one (1) common restroom in the hallway. The restrooms were clean and sanitary with grab bars and slip-resistant surfaces. Between 10:52AM – 10:59AM, LPA measured hot water temperatures in resident restrooms at 108.1 degrees F – 116.2 degrees F, which is within the required range.

Report continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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: SHALOM ELDERLY CARE, INC. 6
FACILITY NUMBER: 197608655
VISIT DATE: 11/19/2024
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COMMON AREAS: These include the living room and dining area. All common areas were observed to be in good condition. There is a screened and inaccessible fireplace in the living room. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 11:05AM and were operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last purchased on 10/21/2024. LPA observed required postings throughout the common areas. Hallways contained supply closets with extra linens and emergency water supply. LPA observed a locked laundry area in the hallway containing locked and inaccessible cleaning supplies, disinfectants, and detergents. All auditory exit devices in bedrooms and common areas were functional and operating at the time of the visit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted.

MEDICATION REVIEW: At 11:08AM, LPA reviewed medications for three (3) residents. Medications are centrally stored and locked in a cabinet in the kitchen area. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors were observed during the medication review.

RECORD REVIEW: Beginning at 11:32AM, LPA reviewed six (6) out of six (6) resident files and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 09/09/2024.



No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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