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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:12:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/14/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230414143432
FACILITY NAME:ELIM HEALTHCARE, INC.FACILITY NUMBER:
197608203
ADMINISTRATOR:TAMMIE CHAFACILITY TYPE:
740
ADDRESS:1126 S. WESTMORELAND AVENUETELEPHONE:
(213) 736-7777
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:142CENSUS: 127DATE:
04/18/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Tammie Cha - AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not provide resident's authorized representative records in a timely manner.
INVESTIGATION FINDINGS:
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 *This report supersedes the report dated 04/17/23 to make gramatical corrections*
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Tammie Cha (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, and interviewed Administrator and Facility's Lawyer. LPA reviewed Resident 1 (R1) entire file.

The investigation revealed the following: regarding the allegation "facility did not provide resident's authorized representative records in a timely manner”, it is alleged that on Friday, April 07, 2023, at 5:10pm the facility received a formal request via Federal Express to obtain a copy of R1's records. The request was made by the resident's legal representative. They were due on Tuesday, April 11, 2023. Administrator and Facility's Lawyer confirmed the formal request was received on April 07, 2023. Facility's lawyer stated that the documents were mailed on April 11, 2023 and received by R1's legal representative on April 12, 2023. R1's legal representative confirmed that the documents were received on April 12, 2023. (Continued to LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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 3
Control Number 28-AS-20230414143432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELIM HEALTHCARE, INC.
FACILITY NUMBER: 197608203
VISIT DATE: 04/18/2023
NARRATIVE
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Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22, Division 6 Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly Article 02.5 Resident's Bill of Rights. Refer to LIC 9099-D.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230414143432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/24/2023
Section Cited
HSC
1569.269(a)(21)
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Enumerated rights; severability. Residents....shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.
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Facility will ensure that Health and Safety Code 1569.269 is met at all times. Additionally, the facility will submit a statement stating that they understand and will comply with this Health and Safety Code to CCLD by 04/24/2023.

*Resident legal representative received resident's records on 04/12/2023*
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This requirement was not met evidenced by:

Based on record review, the facility received a formal request for resident's records on 04/07/23 and failed to provide the records within 2 business days, as required per regulation; which poses a potential health and safety risk to persons in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3