197608203-8-3-2021-28-AS-MVAO-C9XSMD-20211222125943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 08/03/2021
Date Signed: 08/03/2021 03:23:11 PM

Substantiated

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
08/05/2020 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200805140231

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; 142	CENSUS: 68	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jean Kim		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility unable to meet the resident's needs
Facility staff refused to accept resident back from the hospital

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Licensee Jean Kim and explained the purpose of the visit.

The investigation consisted of: On 8/13/20, LPA conducted a telephone interview with Licensee Jean Kim and Facility Consultant Amelia Aladin. LPA also conducted a virtual tour of facility and observed and inspected facility signal system and facility temperature. LPA requested/ received copies of Staff and Resident Rosters, and copies of pertinent documents related to complaint allegations.

LPA received the following documents from Licensee Jean Kim on different dates: On 8/10/20, LIC 624 Unusual Incident/ Injury Reports dated 8/5/20, 8/6/20, 8/7/20, 8/8/20, 8/9/20 and 8/10/20. On 8/11/20, LPA

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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-20200805140231

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: 08/03/2021

NARRATIVE

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received the following documents: Resident 1 (R1's) LIC601 Identification and Emergency Information, R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 6/17/20 and a second one dated 11/22/19, R1 Appraisal/ Needs and Services Plan dated 7/19/20 and 6/1/20, R1's Preplacement Appraisal Information dated 5/19/20, Resident Appraisal dated 6/29/20 and other pertinent documents related to the complaint investigation. On 8/13/20, LPA received the following documents: two copies of medication prescriptions for R1 dated 7/23/20, R1 Medication Administration Record (MAR) for 7/24/20 - 8/9/20, Unusual Incident/ Injury Report LIC624 dated 6/12/20, 7/28/20, 8/2/20 and Staff/ Resident Rosters. On 10/13/20, LPA received the following documents via email from R1's Responsible Party (RP): additional copy of R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 11/22/19 and a copy of R1's hospital medical records.

On 6/8/21, LPA interviewed Administrator Tammie Cha, Licensee Jean Kim, and Staff 1-3. LPA conducted a tour of facility which included the Memory Care Wing that is located on the 2nd floor (Rooms #218-230), LPA also observed and inspected the auditory devices on doors and inspected the thermostatic controls for resident rooms and facility to observe the temperature of resident rooms and the facility.

The investigation revealed the following: In regards to the allegation, Facility unable to meet the resident's needs, it is alleged that facility placed R1 in their Assisted Living (AL) Floor instead of placing the resident in Memory Care. R1 resided at the facility since 6/1/20 until approximately 8/5/20 and RP initially requested that R1 be placed in Memory Care due to primary diagnosis but according to RP, facility licensee stated that R1 would be placed in the AL floor so that R1 could get acclimated to the facility. It is alleged that facility licensee was aware of R1's primary diagnosis when R1 was admitted and still placed R1 in the AL floor of the facility. R1 began wandering on their first night at the facility and also subsequently began going into other residents' rooms. Interview with Licensee Jean Kim revealed that R1 was admitted on 6/1/20 and at that time was able to go to their room by themselves. Ms. Kim stated that R1 then began wandering into other residents rooms and attempting to open a door that leads to a stairwell. Ms. Kim stated that staff immediately redirected R1 and was then immediately re-assessed. Ms. Kim stated that R1 would also disrobe and wander into other residents rooms. Interviews with S1-3 revealed that R1 wandered and had to be monitored closely. S1 stated that R1 needed a higher level of care as R1 tried to constantly leave, took

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200805140231

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: 08/03/2021

NARRATIVE

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clothes off and wandered into other resident's rooms. S2 stated that R1 would take their clothes off, scream at night when redirected and wander into other residents' rooms and take their belongings. S3 stated that R1 would wander a lot and had to be monitored closely. LPA reviewed R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 6/17/20 which was the current LIC602A at time of R1's admission to facility on 6/1/20. LPA observed on Page 2 that one of R1's primary diagnoses was Major Neurocognitive Disorder and had conditions and behaviors in relation to that diagnosis. LPA reviewed R1's Medication Administration Record (MAR) dated 7/24/20-8/9/20 and one of the medications listed is a medication that is used to treat Major Neurocognitive Disorder. LPA also reviewed Unusual Incident/ Injury Reports (LIC624) dated 7/28/20 and 8/2/20 which reported wandering and disrobing behavior in relation to R1.

For the allegation, Facility staff refused to accept resident back from the hospital, it is alleged that R1 was transferred to the hospital on 8/6/20 on a 5150 hold due to being a danger to themselves and others. R1 was allegedly transferred to the hospital in an attempt to evict R1 from the facility. R1 was transported to a hospital that is over 40 miles away from the facility and when R1 was ready to be discharged from the hospital, the facility allegedly did not want to accept R1 back. Interview with Licensee Jean Kim revealed that R1 was transferred to the hospital due to increased exit seeking, disrobing and wandering behavior. Ms. Kim stated that due to COVID-19 it was very difficult to find a hospital that would take R1 which is the reason that R1 was transported to that hospital and not a hospital that is closer to the facility. Ms. Kim stated that the facility did not refuse to take R1 back and due to discharge being on the weekend they had difficulty arranging transportation. She also stated that the facility was not trying to evict R1 but was trying to ensure that the resident was safe as R1 increasingly wandered into other resident's rooms while being unclothed. She stated that the facility never issued an eviction notice to R1. She stated that facility doctor (Dr. Kamel) stated that R1 should not be released yet and that is what they tried to explain to the hospital staff. Ms. Kim stated that there was miscommunication between the facility staff and the hospital staff. LPA review of R1's hospital medical records revealed that R1 was admitted to the hospital on 8/6/20 and was observed to be calm, pleasant and conversing in a soft tone at time of admission. R1 was oriented and confused. Hospital records indicate that R1 was cooperative when redirected when R1 wandered, no agitation or aggression noted. Hospital records reveal that hospital social worker called the facility on 8/7/20 to inquire about R1 returning to facility once stable for discharge and at that time was told by a facility staff (Esther Sue, RN) that R1 could not come back to the facility as it was not safe due to R1 wandering into others rooms and the

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200805140231

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: 08/03/2021

NARRATIVE

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facility not having 24 hour care. On 8/8/20 hospital social worker spoke to the same facility staff who stated that they would take R1 back as long as the doctor said that it is safe for R1 to go to an unlocked facility and requested documentation indicating that. On the same day social worker received a call from Dr. Kamel who told hospital social worker that R1's discharge was "unsafe and not appropriate". Hospital notes also state that Dr. Kamel yelled at social worker despite social worker attempting to provide information about medical clearance. Dr. Kamel continued to yell and abruptly hung up on social worker mid call. Social worker then called facility Licensee who stated that they would take R1 back but she had to go by the doctor's orders. SW reiterated to licensee that doctor at hospital had cleared R1 for discharge and R1 did not meet the criteria of exit seeking. Licensee stated to SW that they did not have room in the facility locked unit but would schedule an ambulance but did not know what company as she had to call a few places due to places not being open on Saturday. R1 was eventually discharged to daughter due to facility changing positions on R1's return to facility on 8/8/20.

Based on interviews conducted with facility staff and LPA review of documents, the preponderance of evidence standard has been met; therefore, the above mentioned allegations are found to be SUBSTANTIATED.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. (Refer to LIC 9099D).

Exit interview was conducted with Licensee Jean Kim. A copy of the report and appeal rights were provided to Administrator.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 28-AS-20200805140231

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 08/10/2021 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in...This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	Based on LPA interviews and record review, the licensee failed accept R1 back to the facility upon discharge from hospital and did not provide R1 with a 30 day eviction notice which poses a potential Health, Safety or Personal Rights risk to the residents in care.	8 9 10 11 12 13 14
Request Denied Type B 08/10/2021 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	Basic Services "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.	1 2 3 4 5 6 7	Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPA interviews with staff which revealed that R1wandered and had to be monitored closely and required redirection and review of R1's records which indicated R1 had a primary diagnosis of Major Neurocognitive disorder at time of admission and was placed in the assisted living floor, which poses a potential Health, Safety or Personal Rights risk to the residents in care.	8 9 10 11 12 13 14

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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

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