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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 10/10/2022
Date Signed: 10/10/2022 02:34:50 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
09/30/2020 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200930114828
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: 122DATE:
10/10/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Tammie Cha TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
** This report will supersede report dated 9/24/21. Additional visit was required to conduct resident interviews, there are no changes in the findings**

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA met with Administrator Tammie Cha and explained the purpose of the visit.

On visits conducted 10/7/2020 and 9/24/21 the visits consisted of: LPA conducted a telephone interview with Staff #1-#6 (S1-S6) and conducted a virtual tour of the physical plant. LPA reviewed copies of Staff and Resident Rosters, and copies of pertinent documents related to complaint allegations. LPA was unable to interview Resident #1 (R1) as R1 is no longer in the facility. LPA reviewed R1's file.

On todays visit, LPA interviewed Resident #2-#10 (R2-R10).... Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
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 2
Control Number 28-AS-20200930114828
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: 10/10/2022
NARRATIVE
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9
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13
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20
21
22
23
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26
27
28
29
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31
32
** This report will supersede report dated 9/24/21. Additional visit was required to conduct resident interviews, there are no changes in the findings**

The investigation revealed the following: In regards to the allegation, "Staff do not safeguard resident's personal belongings" it was alleged that R1's money and personal belongings were being stolen by staff. (6) of (6) staff interviewed denied the allegation. (9) of (9) Residents interviewed could not corroborate the allegation. Review of resident documents does not show that the facility managed R1's money or was entrusted to safeguard residents personal property. Interviews show that when visitors leave money or items to the residents they visit, the staff are not made aware of what they are given. LPA was unable to interview R1 for more information due to R1 no longer being available to contact. Based on interviews conducted, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation; therefore, the allegation is UNSUBSTANTIATED.

A copy of this report was provided to administrator Tammie Cha.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2