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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:52:42 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
01/06/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210106160023
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:
11/03/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jean Kim TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility not communicating changes in resident to responsible party.
Resident is not being bathed
Resident's clothes are not being changed
Staff do not have a Dr. order to crush medications for resident
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, Jean Kim who assisted with today's visit.

The investigation consisted of interviews with Administrator, Staff #1- Staff #4, and review of resident #1's file. Resident #1 moved out of the facility on 1/16/21, and was not interviewed. Regarding the allegation that the facility is not communicating changes in resident to responsible party, Administrator and staff interviewed denied the allegation. They stated that they do communicate changes in a resident, to the resident's responsible party. Regarding the allegation that resident is not being bathed, and residents clothes are not being changed, Administrator and staff stated that they do assist residents with bathing and with dressing. However, they stated that resident #1 was very combative and refused to be bathed and changed. Administrator provided documentation for residents who receive assistance with showering. Regarding the allegation that staff do not have a Doctor's order to crush medications for resident, Adminstrator and staff interviewed denied the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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-20210106160023
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: 11/03/2022
NARRATIVE
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They stated that they follow Doctor's orders, and only crush medication if there is a Doctor order. LPA reviewed documentation indicating which residents have doctors order for crushing medication.

Based on LPA's observations 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. Exit interview conducted, and a copy of report was provided to Administrator, Jean Kim.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2