197608203-8-20-2021-28-AS-MVAO-C9XSMC-20211222125943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:42:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2020 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200805140231

FACILITY NAME:	ELIM HEALTHCARE, INC.		FACILITY NUMBER:	197608203
ADMINISTRATOR:	TAMMIE CHA		FACILITY TYPE:	740
ADDRESS:	1126 S. WESTMORELAND AVENUE		TELEPHONE:	(213) 736-7777
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90006
CAPACITY:	142; 142	CENSUS: 68	DATE:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Yang Sook Chai		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility did not seek timely medical attention for resident
Facility provided inadequate supervision.
Facility did not have auditory device on doors exiting to stairwells.
Facility not communicating changes in resident to responsible party.
Temperature is not within acceptable range in resident's room.
Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Staff (LVN) Yang Sook Chai and explained the purpose of the visit.

The investigation consisted of: On 8/13/20, LPA conducted a telephone interview with Licensee Jean Kim and Facility Consultant Amelia Aladin. LPA also conducted a virtual tour of facility and observed and inspected facility signal system and facility temperature. LPA requested/ received copies of Staff and Resident Rosters, and copies of pertinent documents related to complaint allegations.

LPA received the following documents from Licensee Jean Kim on different dates: On 8/10/20, LIC 624 Unusual Incident/ Injury Reports dated 8/5/20, 8/6/20, 8/7/20, 8/8/20, 8/9/20 and 8/10/20. On 8/11/20, LPA

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20200805140231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 08/20/2021

NARRATIVE

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received the following documents: Resident 1 (R1's) LIC601 Identification and Emergency Information, R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 6/17/20 and a second one dated 11/22/19, R1 Appraisal/ Needs and Services Plan dated 7/19/20 and 6/1/20, R1's Preplacement Appraisal Information dated 5/19/20, Resident Appraisal dated 6/29/20 and other pertinent documents related to the complaint investigation. On 8/13/20, LPA received the following documents: two copies of medication prescriptions for R1 dated 7/23/20, R1 Medication Administration Record (MAR) for 7/24/20 - 8/9/20, Unusual Incident/ Injury Report LIC624 dated 6/12/20, 7/28/20, 8/2/20 and Staff/ Resident Rosters. On 10/12/20, LPA spoke to Huntington Hospital Social Worker, Martha Celis. LPA attempted to reach Orange County Global Medical Center Social Worker, Laura Morales on 9/22/20, 10/7/20 and 10/12/20 but was not able to establish communication with social worker. On 10/13/20, LPA received the following documents via email from R1's Responsible Party (RP): additional copy of R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 11/22/19 and a copy of R1's hospital medical records.
On 6/8/21, LPA interviewed Administrator Tammie Cha, Licensee Jean Kim, and Staff 1-3. LPA reviewed R1's facility file, conducted a tour of facility which included the Memory Care Wing that is located on the 2nd floor (Rooms #218-230), LPA also observed and inspected the auditory devices on doors and inspected the thermostatic controls for resident rooms and facility to observe the temperature of resident rooms and the facility.

On 8/3/21, LPA conducted interviews with R2-7 from 2pm-3pm. On 8/20/21, LPA attempted to interview facility doctor by phone.

Investigation revealed the following: Regarding allegation, Facility did not seek timely medical attention for resident, it is alleged that on 6/8/20, R1's family member noticed that R1's legs were swollen and family member mentioned it to the facility nurse who did not seek timely medical attention for resident. R1's legs got worse four days later and until then R1 was taken to the hospital. R1 returned to the facility but was not quarantined. Interview wit Administrator Tammie Cha revealed R1 was taken to the hospital to be assessed once R1 complained of pain to their right foot. R1 was assessed immediately by facility staff and R1 complained of pain to touch. Administrator stated that doctor was notified and facility received an order to send R1 to the hospital emergency room. Administrator stated that facility staff assisted R1 to the hospital as R1's RP was not available. She stated that R1 returned to the facility that same day and orders were noted

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20200805140231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 08/20/2021

NARRATIVE

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and carried out by facility. She also stated that R1 received an Ultrasound to follow up on medical condition on 6/16/20. Administrator stated that when R1 returned to the facility she was quarantined as that is the procedure that is set in place. She also stated that R1 had a private room and did not have a roommate. LPA reviewed facility notes regarding R1 and observed that R1 was assessed by facility staff on 6/12/20 and sent to the hospital the same day and then got an ultrasound to follow on condition on 6/16/20. Interviews conducted with facility staff revealed that if they notice any resident that needs medical attention it is immediately addressed. Interviews conducted with R2-7 revealed that they are happy at facility and stated that staff tend to their needs and if they have a medical condition facility staff will seek timely medical attention. Based on interviews conducted with facility staff, facility resident, and LPA record review, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility provided inadequate supervision, it is alleged that R1 wandered into facility stairwells and made it down to where stairwell leads to garage. Interviews conducted with facility staff revealed that no resident has wandered into facility stairwells and denied that R1 or any other resident has made it to where the stairs lead to the garage. Staff stated that there are enough staff on schedule at all times to properly supervise facility residents. Interviews conducted with R2-7 revealed that they believe staff properly supervise residents and stated that there are enough staff on schedule. LPA reviewed R1's facility notes and did not observe any reports stating that R1 wandered into the stairs leading to the garage and observed notes stating that R1 was oriented to call light and demonstrated understanding. LPA reviewed facility staff schedule and observed that there are enough staff on schedule to care for the residents in placement. During facility tour, LPA also observed facility properly supervising and tending to residents needs. Based on interviews conducted with facility staff, facility residents, and LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility did not have auditory device on doors exiting to stairwells, it is alleged that facility did not have an alarm on the door which opens to stairs leading to the facility garage to alert staff when a resident attempts to exit. Interviews conducted with facility staff revealed that all doors leading to stairwells have an auditory device to alert staff if a resident is attempting to exit. Interviews conducted with 4 out of 7 residents revealed that they have heard the alarms go off but do not know what doors the alarms are for. On 8/13/20 and 6/8/21, LPA observed that auditory devices on doors exiting to stairwells were properly functioning. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20200805140231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 08/20/2021

NARRATIVE

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For the allegation, Facility not communicating changes in resident to responsible party, it is alleged that facility staff did not report to RP about R1 wandering into other residents rooms and due to that other residents yell at R1. It is also alleged that facility doctor made inappropriate comments regarding R1. Interviews conducted with facility staff revealed that they properly report all important changes regarding all residents to their responsible parties if they have any and stated that they have never made any inappropriate comments regarding any resident and have not heard any one else including the facility doctor make inappropriate comments regarding R1 or any other resident. Staff also stated that they did not observe residents yelling at R1. Staff did state that R1 had to be redirected as they would wander into other residents rooms. Licensee stated that facility was properly notifying R1's RP about R1 wandering. Interviews conducted with 4 out of 7 residents revealed that facility staff properly communicate changes to their responsible parties and they are satisfied with the services they receive at the facility. LPA attempted to interview facility doctor who stated to LPA that he no longer works at the facility and did not have anything to say as it is "over". Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Temperature is not within acceptable range in resident's room, it is alleged that thermostat in R1's room was set to 82 degrees Fahrenheit but that due to the floor resident's room is located resident gets more heat and as a result resident started taking their clothes off at night. Interviews conducted with facility staff revealed that facility temperature is maintained at a comfortable level at all times. Facility staff stated that the temperature is set at comfortable temperature ranges and also stated that when it is very hot outside they will set the temperature at an appropriate level based on the outside temperature. Interviews conducted with 7 out of 7 residents revealed that facility temperature is always comfortable and they have never felt too hot in their rooms or anywhere in the facility. On 8/13/20 and 6/8/21, LPA toured facility including all floors and observed facility temperature and observed that temperature was set at an appropriate and acceptable range. During tour conducted on 6/8/21, LPA observed the facility temperature to be cool on all facility floors. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Illegal Eviction, it is alleged that R1 was taken to the hospital against responsible party's orders. It is also alleged that the facility will not take R1 back once discharged from the hospital and that facility is going to illegally evict R1. Facility placed R1 on a 5150 hold and then cashed August 2020 rent

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20200805140231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 08/20/2021

NARRATIVE

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check and facility will not give the money back if the facility evicts R1. Interviews conducted with Licensee Jean Kim revealed that the facility never evicted R1 and never served R1 or R1's RP with an eviction notice. Licensee stated that R1 was sent to the hospital based on the doctors orders and once R1 was properly discharged the facility was going to accept the resident back but stated that R1's RP did not want R1 returning to the facility and requested a refund and collected all of R1's belongings including medications on 8/9/20. Licensee stated that a check was written to R1's RP providing a refund as well as documentation regarding release of R1's belongings and medication. LPA reviewed R1's file and did not observe an Eviction Notice. LPA did review a copy of a check written to R1's RP for refund and also reviewed documentation regarding release of R1's belongings and medication. Based on interviews conducted with facility staff, R1's RP and LPA review of documentation, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Staff (LVN) Yang Sook Chai.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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