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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608203
Report Date: 01/24/2023
Date Signed: 01/24/2023 10:57:21 AM


Document Has Been Signed on 01/24/2023 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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
ADMINISTRATOR:TAMMIE CHAFACILITY TYPE:
740
ADDRESS:1126 S. WESTMORELAND AVENUETELEPHONE:
(213) 736-7777
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:142CENSUS: 126DATE:
01/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tammie Cha, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Galarza and Erik Zaragoza conducted a Case Management- Incident visit to follow up on an incident report submitted to the District Office on 1/19/2023. LPAs met with Office Manager Dong Kang. Administrator arrived shortly after. The purpose of today's visit is to check on the health & safety of residents in care.

On January 19, 2023 at 7:20 AM, resident (R1) was found in the laundry room confused, with signs of toxin poisoning. Three (3) laundry detergent liquid pods were observed to be missing half the liquid inside. Paramedics were called at 7:40 AM and the resident was transported to the hospital. The resident is still hospitalized.

During today's visit the following was conducted:


  • A physical plant tour of the facility focusing on laundry rooms, storage areas, and common areas.
  • Review of resident (R1's) file.
  • Obtained R1's file documents [Face Sheet, Physician's Report, and Resident Appraisal]

Per Plan of Operation, "Any materials that may pose a hazard to resident's...., because of their cognitive level may ingest them, are kept in locked storage and are inaccessible to residents. Staff are trained to observe for these materials and proper storage."

A deficiency was cited according to Title 22. See LIC 809D.


An exit interview was with Administrator Tammie Cha. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/24/2023 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2023
Section Cited

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Care of Persons with Dementia. Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met evidenced by:
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Administrator agreed to:
1. Submit proof of staff in-service training.
2.Submit a written plan of correction that states what was done to correct the deficiency.
3. Reasses R1 and update MD Report.

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Based on observation, the 2nd floor Dementia floor's laundry room doors are kept unlocked, and as a result R1 ingested 3 laundry detergent pods. During today's visit, the laundry door had a working lock, but staff placed tape on the latch bore in order to keep the door unlocked so that a key is not needed. This poses an immediate health & 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2