197608203-7-20-2023-28-AS-RORN-CU5N85-20230727101347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 07/20/2023
Date Signed: 07/20/2023 07:52:32 PM

Substantiated

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
04/16/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210416112753

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: 124	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Licensee Jean Kim		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not notify an authorized representative of a resident being transferred

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Licensee Jean Kim and the purpose of the visit was discussed.

Initial visit conducted virtually on 4/23/21 consisted of the following: LPA Villalobos conducted a telephonic interview with staff #1-#3 and requested the following documents by 4/29/21: staff roster, resident roster, Emergency and Identification page and current physicians report for Resident #1(R1), Doctors order for transfer of R1, Discharge documentation, Resident Appraisal, and Individual Services Plan. LPA Villalobos unable to interview R1 due to not residing in the facility any longer.

On todays visit LPA Villalobos reviewed above listed documents and interviewed Staff #4 (S4) and residents #2-#4 (R2-R4). R1 remains unavailable for interview. The investigation revealed the following:

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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 5

Control Number 28-AS-20210416112753

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: 07/20/2023

NARRATIVE

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In regards to the allegation "Staff did not notify an authorized representative of a resident being transferred" it was alleged that R1 was transferred to a skilled nursing facility on 12/16/20 without prior notification to their responsible party / power of attorney. (2) of (4) Staff interviewed denied the allegation. (3) of (3) Residents interviews could not corroborate the allegation. Interviews with staff show that on that day R1 was having knee pains and doctor gave orders to transfer R1 to a skilled nursing facility at 5pm. Review of doctors orders confirms that information but does not have signature that authorized agent reviewed and agreed. Special incident report timed R1 being transferred at 5:10pm. Staff notes and interviews state that R1's responsible party and family visited the facility that same night and that is when they were notified of the transfer. This shows that the facility failed to notify R1's responsible party of R1's transfer to a skilled nursing facility.
Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22 on separate 9099-D page.

An exit interview was conducted. A copy of the report an appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210416112753

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/03/2023 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8)To have their representatives regularly informed by the licensee of activities related to care or services including ongoing evaluations,	1 2 3 4 5 6 7	Facility to conduct in service training on review of Personal Rights of Residents in All Facilities (87468.1) to staff involved in creating reports and provide signature page of completion to Licensing by POC due date.
	8 9 10 11 12 13 14	as appropriate to their needs. This was not met as evidenced by: R1 being evaluated and transferred to a skilled nursing facility without notifying R1's responsible party. This poses a potential health and safety risk to residents in care and supervision.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/16/2021 and conducted by Evaluator Jose Villalobos

COMPLAINT CONTROL NUMBER: 28-AS-20210416112753

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: 124	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Licensee Jean Kim		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility has inadequate record keeping regarding a resident being transferred

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210416112753

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: 07/20/2023

NARRATIVE

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In regards to the allegation "Facility has inadequate record keeping regarding a resident being transferred" it was alleged that the facility did not properly document R1's transfer from the facility to a skilled nursing facility. (4) of (4) Staff denied the allegation. (3) of (3) Residents interviewed could not corroborate the allegation. Interviews show that the facility has documentation of doctors order for the transfer of R1. Special incident report was created in a timely manner regarding R1's transfer and the reason for transfer matches what is listed on the doctors order. LPA was not provided proof of there being errors or mistakes in the documentation of R1's transfer. Based on interviews and files reviewed; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit Interview conducted and copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5