197608203-6-22-2023-28-AS-RORN-CT3RTJ-20230623131824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:23:26 PM

Unsubstantiated

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
11/15/2022 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221115101026

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	CENSUS: 119	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Tammie Cha		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff inappropriately charged resident for adult briefs.
Facility staff did not ensure that resident received their medication while in care.
Facility staff restrained resident to a wheelchair while in care.
Facility would not take resident back after discharges from hospital.
Resident is being illegally evicted from the facility.
Facility staff does not give residents adequate time to eat a meal.
Facility failed to notify residents responsible party of change of condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted a subsequent complaint investigation for the allegations listed above. Upon arrival, LPA met with receptionist Phoebe Lee and shortly after met with Administrator Tammie Cha and explained the purpose of the visit. This licensing report supersedes licensing report from visit 11/21/22.

Investigation consisted of the following: the initial complaint visit was conducted on11/21/22. A subsequent visit was conducted on 6/22/23. During subsequent complaint visit, LPA conducted interview with Administrator Tammie Cha and telephonically interviewed social worker for Resident #1(R1). LPA collected staff and resident roster, R1’s medication orders by Doctor / Pharmacy and Prescription List , Lab order report , Assisted Living Wavier Individual Service Plan dated 2/28/22, Medication Log for 2/1/22, Doctor Report for 2/3/22, 2/17/22, 5/19/22 and Hospital Discharge Medication Order Report (Weight Information) dated 6/7/22. LPA re-delivered the updated complaint investigation findings and findings will remain the same. (Continuation on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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 6

Control Number 28-AS-20221115101026

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: 06/22/2023

NARRATIVE

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Regarding Allegation: Facility staff inappropriately charged resident for adult briefs. The investigation consisted of the following: on 11/21/22, LPAs interviewed 12 out of 13 residents regarding the above allegation, residents stated for supplies like adult briefs and other resident supplies, the facility does not charge residents directly and bills the resident’s medical insurance. LPA Calderon interviewed R1 via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. On 11/21/22, LPAs interviews with staff revealed that 5 out of 5 staff reported that the facility did not charge family and/or residents for adult briefs and other resident supplies and staff confirmed that R1 was incontinent. Administrator stated for residents who need certain supplies such as adult briefs, the facility places an order using a third-party supply company and facility does not charge families and/or residents directly. LPA reviewed Pre-Placement Appraisal dated 12/20/21 which indicates R1 needs incontinent care. Physician Report dated 12/20/21 states R1 has a bladder impairment and unable to care for own toileting needs. LPA Calderon reviewed R1’s Incontinence Supplies Prescription form/ order for adult brief and other supplies signed by doctor for Incontinence Supply order on 1/24/22. LPA reviewed documents from a third-party supply company for incontinence supply approval request including adult briefs, for R1 was approved by insurance. LPA reviewed documentation stating R1’s medial insurance provided incontinence supply services through third party medical supply company, services provided from 1/27/22- 1/24/23. Tammie during 6/22/23 interview stated to LPA upon R1’s admission and until medical insurance approved incontinent supplies for R1, facility provided incontinent supplies like adult briefs that facility provides to residents in need. LPA reviewed Delivery Ticket’s from third-party supply company; supplies for R1’s Incontinence supplies orders for dated 7/25/22, 8/24/22, and 9/23/22. The documentation revealed orders were going through R1’s medical insurance company and facility was billing R1’s primary and secondary insurance. There is no evidence to support that the facility was inappropriately billing resident for adult briefs.
Regarding Allegation: Facility staff did not ensure that resident received their medication while in care. The investigation consisted of the following: LPA Calderon interviewed R1 via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. On 11/21/22, LPAs interviews with 12 of 13 residents revealed that residents take all their medications and have no issues with medications or knowledge of any residents that did not receive medications while in care. LPA Calderon interviews with staff conducted on 11/21/22 revealed that the Director Jean Kim reported that she handles reporting of facility incident reports and Director Kim reported that there were no incidents regarding R1 not taking any medications during R1 placement at the facility.
(Continuation on 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20221115101026

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: 06/22/2023

NARRATIVE

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Administrator reported that medications were prescribed by R1 physician and were provided to R1. Administrator stated R1s physician discontinued R1s medications via written order dated 02/03/22. Staff interviews conducted on 11/21/22, indicated that five (5) staff reported not being aware of facility not providing and/or not assisting resident(s) with medication. LPA reviewed Medication Log for R1 for Month October 2021 and medications listed and ordered by physician were provided to R1 occurring to doctor’s orders. LPA reviewed Facility Narrative Chart dates 2/14/22, 2/15/22, 2/22/22, 3/10/22, 5/5/22, 5/25/22,7/11/22,7/13/22, 10/5/22, and 10/6/22 indicated medication ordered by doctor for R1 and provided to R1 and Responsible Part made aware. Physician Orders and Facility Narrative Charts collected from facility which documented staff were providing R1 with medications and R1s medications were discontinued based on doctors’ orders. Therefore, based on interviews with staff and residents, record review including R1 medication log and written orders, the investigation did not reveal any evidence to support that facility staff did not ensure R1 was receiving medications while in care.

Regarding Allegation: Facility staff restrained resident to a wheelchair while in care. The investigation consisted of the following: LPA Calderon interviewed Resident #1 (R1) via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. On 11/21/22, LPAs interviews with 12 of 13 residents revealed that residents have not observed facility staff tying residents down to wheelchairs. Two (2) of the thirteen (13) residents reported using a wheelchair and are not being tied down by staff. Interviews conducted on 11/21/22 with staff revealed that five (5) out of five (5) staff denied staff tying down residents or having knowledge of staff tying/restraining residents to a wheelchair. Administrator reported that the facility provided R1 with a wheelchair accessory – a lap tray, a table that attaches to the wheelchair, however, the accessory is not used to restrain or tie down R1. Interview conducted on 05/17/23, indicated Administrator reported a physician’s order was in place for R1 wheelchair lap tray. LPA reviewed doctors order dated 9/3/2022 which indicated R1 may have wheelchair lap tray. During the initial visit conducted on 11/21/22, LPA Calderon observed residents with wheelchairs and did not observe any residents being retrained or tied down to a wheelchair. Therefore, based on observations, interviews, and record reviews there was no evidence revealing facility staff restrained R1 to a wheelchair.

(Continuation 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20221115101026

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: 06/22/2023

NARRATIVE

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Regarding Allegation: Facility would not take resident back after discharges from hospital. The investigation consisted of the following: LPA Calderon interviewed Resident #1 (R1) via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. On 11/21/22, LPA interviews with 12 of 13 residents revealed that residents were not aware of hearing of residents not being allowed to return to the facility after being discharged from the hospital. Interviews with two (2) of the thirteen (13) residents, indicated that the residents have received care at the hospital and/or rehabilitation center and facility accepted the resident back to the facility upon discharge. Staff interviews conducted on 11/21/22, revealed that five (5) out of five (5) staff reported that the facility does not refuse residents from returning to the facility after being hospitalized. Director Kim reported residents are accepted back from the hospital, however, facility follows physician’s determination regarding the resident’s level of care and what care / placement is needed for resident. Facility Narrative Charting reviewed by LPA the documentation states that on 10/06/22, R1 saw doctor and doctor recommended skilled nursing and Responsible party was notified. Interview on 11/21/22 with Administrator reported that R1 was transferred to the hospital on 10/7/22 and follow up from hospital stated discharge plan was for R1 to be transferred to a skilled nursing program. LPA Calderon reviewed Facility Narrative Charting dated 10/7/22, stating doctor requested R1 due to lab results for R1 to be transferred to the hospital and responsible party was made aware. LPA Calderon reviewed Unusual Incident Report dated 10/07/22, the incident report indicated that Good Samaritan Hospital called facility on 10/14/22 and stated R1 needs skilled nursing care. LPA Calderon interviewed a Social Worker from Good Samaritan Hospital on 5/17/22 and the Social Worker stated doctors discharge plan was to provide R1 with an appropriate level of care and hospital will transfer R1 to a skilled nursing facility. Therefore, based on interviews, observations and record review, the investigation revealed that the above facility is licensed as a Residential Care Facility for Elderly and does not have the ability to provide nursing care to R1 or facility residents. Interview on 6/22/23 with R1 social worker stated R1 was dicharged from Good Smaratian on 10/18/22 and transfered same day to skilled nursing facility. The investigation revealed that R1 required transfer to skilled nursing upon discharge from the hospital and investigation did not reveal that the facility refused to accept R1 back to the facility.

(Continuation on 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20221115101026

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: 06/22/2023

NARRATIVE

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Regarding Allegation: Resident is being illegally evicted from the facility. The investigation consisted of the following:LPA Calderon interviewed Resident #1 (R1) via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. Interview with 3 out of 3 staff revealed staff not containing knowledge regarding eviction letter distributed to R1. Interview with R1 family member dated 11/21/22, family member stated no eviction letter was provided although facility did not accept R1 back after hospital stay. On 11/21/22, LPA interviewed Administrator who reported that R1 was not evicted and stated that R1 was transferred to the hospital upon needing medical care and doctor order and facility reported the incident to Licensing via an Unusual Incident Report dated 10/7/22. Incident Report states R1 seeking care at Good Samaritan Hospital and R1 needs skilled nursing care. Interviews from 11/21/22 with Administrator and Director Kim indicated that R1 was not provided an eviction letter and was not illegally evicted. Therefore, based on Good Samaritan Hospital discharge plan for R1, R1 was transferred to an appropriate level of care. The investigation did not reveal evidence to support that the facility illegally evicted R1 from the facility.

Regarding Allegation: Facility staff does not give residents adequate time to eat a meal. The investigation consisted of the following: on 11/21/22, LPAs interviews with 12 of 13 residents reported not having a time frame for mealtimes and/or are not getting their food taken away after 30 minutes of eating by facility staff. Resident #4 during interview with LPA reported not having a time frame and residents are able to sit and enjoy the meals even those who are slow eaters. LPA Calderon interviewed R1 via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. LPA Calderon interviewed 5 out of 5 staff during interviews on 11/21/22 reporting that mealtimes aren't timed. Interview with Director Kim on 11/21/22 reported no time frame during meal time and no time frame provided. Administrator Tammie’s interview reported residents eating varies based on needs and staff assist residents who need assistance when feeding. Tammie reported R1 was encouraged to eat and was on appetite stimulator medication. Physician Report dated 12/20/21 states R1 is able to feed self. On 11/21/22, LPA Calderon observed two dining room areas were residents were observed to eat at their own pace, Therefore, no indication was observed that residents were not provided adequate time to eat meals.

(Continuation on 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20221115101026

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: 06/22/2023

NARRATIVE

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Regarding Allegation: Facility failed to notify residents responsible party of change of condition. The investigation consisted the following: LPA interviewed Resident #1 (R1) via telephone on 5/15/23 when asked interview questions R1 stated they cannot remember information. LPAs interview with Administrator conduced on 11/21/22, 5/24/23 and 6/22/23, revealed that R1 family member / R1 responsible party (R.P) was notified about R1’s change of condition for medication regarding weight, doctor visits for R1 medical needs and changes, R1 medication changes, and any incidents that occurred with R1 via verbally and Tammie stated R1 family member was weekly present at facility visiting R1 and would communicate with family member. LPA reviewed Unusual Incident Reported for R1 dated 6/07/22, 6/21/22 and 10/7/22 indicating R1 family member / R1 reporting party was made aware of R1 change of condition seeking medical professional assistance. LPA reviewed Facility Narrative Charting, dates 3/3/22,5/5/22, 6/2/22,6/16/22, 7/5/22 and 10/6/22 state doctor seen and assisted R1 due to medical changes and responsible party for R1 was notified. Facility Narratives dated 12/21/21 states R1’s responsible party made aware of R1’s physical therapy evaluation and treatment order for R1. Facility Narrative 12/22/21 states R1’s responsible party was notified by facility regarding R1 needing chest X-ray’s due to doctor’s order. LPA Calderon reviewed Facility Narrative Chart for date 2/16/22 stating lab order was received and R1’s R.P was notified. Interview on 6/22/23 with Tammie stated lab order was provided by doctor that was present at the facility seeing R1 in person and lab was done because of R1 change of condition.LPA Calderon reviewed Physician Report dated 12/20/21, which stated R1 was on a No Added Salt diet R1’s responsible party signed documentation. LPA reviewed R1’s Assisted Living Wavier/ Individual Service Plan dated 2/28/22 and 8/6/22, R1’s responsible party signed documentation. Therefore, based on interviews and record review R1’s responsible party had communication with facility regarding R1’s changes of condition.

Based on LPA's observations, record review and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22 was provided on today's visit. Exit interview conducted, and a copy of the licensing report were provided to Administrator Tammie Cha.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6