Pre-licensing visit·May 21, 2025

Licensing Program Analysts (LPAs) Quoc Huynh and Kelly Dulek conducted a pre-licensing visit to the above noted facility. At 10:20AM, the LPAs met with applicant, Izhak Illouz. An application to operate a Residential Facility for the Elderly was submitted on 12/02/2024. A dementia program was included in the plan of operation. A Hospice Waiver for 6 (six) has been requested. The facility's fire clearance was approved on 01/03/2025 for 1 (one) bedridden and 5 (five) non-ambulatory, with a total capacity of 6 (six) residents. Component II orientation was completed on 04/14/2025. Component III was completed with the applicant during today's visit. The facility is a single story home located in Valley Village. Beginning at 10:35AM, a physical plant tour was conducted. The following was observed: 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 foods and emergency food supply is adequate. Cleaning supplies are stored in a locked cabinet under the kitchen sink. 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. Medication will be stored in a locked kitchen cabinet. First aid kit was observed to be complete, including a thermometer and a current version of a first aid manual. Files will be stored in a separate locked kitchen cabinet. Washer and dryer were observed in the kitchen area and appeared to be operable. The facility has six (6) resident bedrooms. Bedrooms #4, #5, and #6 have direct access to the outside. Bedridden resident is allowed in resident bedroom #6. Resident rooms are set up with beds, nightstands, lamps, chairs, sufficient clothing storage 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 Report Continued on LIC 809-C. 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. All rooms were free of odors. All window screens were clean and maintained in good repair. There are 6 (six) bathrooms in the facility; 5 (five) are for private resident use and 1 (one) is for shared use. The resident bathrooms have a shower with slip-resistant materials and available mats. The toilet and shower have grab bars. The hot water temperature was tested in various bathrooms and measured within the required range of 105*F to 120*F. 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. 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 available. The facility has central heating and air conditioning to maintain rooms to a comfortable temperature. At 10:52AM, the hardwired combination smoke and carbon monoxide detectors as well as fire doors were tested and functioned properly. The fire extinguishers throughout the facility were fully charged and last serviced on 01/03/2025. 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 shed and detached garage. There is a functioning telephone on the premises. All required postings are posted near the entrance of the facility. 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 outdoor space is property gated. There are locked storage sheds in the back yard. There are no bodies of water on the premises at the present time. 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.