197608203-1-18-2024-28-AS-LHIS-CZQP8S-20240122100602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 01/18/2024
Date Signed: 01/18/2024 11:58:10 AM

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
07/15/2022 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220715100758

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: 127	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tammi Cha		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not care for resident in accordance with physician's orders.
Resident was fed toxic substances while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Tammie Cha who assisted with today's visit.

Regarding the allegation that : Staff did not care for resident #1 in accordance with physician's orders. The investigation consisted of interview with Administrator, and review of resident #1's file, including Physician's orders and Medication administration record (MAR). The investigation revealed that resident #1 lived at the facility from 1/25/22 - 4/22/22. Administrator stated that the facility did follow physician's orders, in providing care to resident #1. Review of MAR indicates that facility was following physician's orders and resident #1 was taking medication as prescribed. LPA observed documentation that resident #1 was seen by physician on 4/21/22. Administrator stated that resident #1's physician ordered labwork to be done. The labwork was done on 4/20/22. On 4/22/22, resident #1's lab results were obtained by facility, and physician was notified. Administrator stated that resident #1's physician ordered resident to be sent to Emergency Room (ER) due to abnormal lab results. Administrator stated that resident #1's family was notified, and resident was sent to ER. Facility submitted a special incident report as required.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220715100758

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: 01/18/2024

NARRATIVE

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Regarding the allegation that resident #1 was fed toxic substances while in care. The investigation consisted of review of resident #1 hospital records, and interview with Administrator. Administrator denied that resident #1 was fed toxic substances while in care. Review of hospital records indicate that there was no evidence of poisoning that could be identified and therefore full toxicology was not sent.

Based on LPA's observations and interviews, investigation revealed: Although the allegation(s) 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.

Exit interview conducted, and a copy of report was provided to Administrator, Tammie Cha.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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