197608203-11-21-2022-28-AS-RORN-CT3RTK-20230623131825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608203
Report Date: 11/21/2022
Date Signed: 11/21/2022 05:31:15 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
11/15/2022 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221115101026

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: 119	DATE:	11/21/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator - Jean Kim		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility staff inappropriately charged resident for adult briefs.
Facility staff did not ensure that resident received their medication while in care.
Facility staff restrained resident to a wheelchair while in care.
Facility would not take resident back after discharges from hospital.
Resident is being illegally evicted from the facility.
Facility staff does not give residents adequate time to eat a meal.
Facility failed to notify residents responsible party of change of condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation to the facility. Upon arrival, LPA met with Tammie Cha (Administrator) and Jean Kim (Licensee) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters. LPA Calderon toured with Tammie common areas, dinning rooms during lunch time, toured rooms of residents in 217B ,314 A & B , 316A, 317B all who use wheelchairs. LPA interviewed Administrator, Licensee, Staff #1-3 (S1 -S3), and residents #2-13 (R2-R13). LPA Calderon collected Face Sheet, Admission Agreement, Facility Narrative Charting, Physician Report, Medical Doctor Visit Reports, Weight and Vital Sign Record, L.A Medical Supply for Incontinence Care, Individual Service Plan for Home Health Services, Medication Log Records, 3 different Unusual Incident Reports, Elim Discharge Report and Physical Therapy Evaluation Report.

Continuation on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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 4

Control Number 28-AS-20221115101026

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: 11/21/2022

NARRATIVE

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Regarding Allegation: Facility staff inappropriately charged resident for adult briefs. LPA Calderon interviewed 12 out of 13 residents all denied allegation and stated facility supplies adult brief and other supplies and facility uses insurance to bill. 4 out of 5 staff stated and denied allegation of charging family for adult brief and supplies. 1 out 4 did not know. Administrator stated " upon admission, residents who need certain supplies or adult briefs we do the orders so we can have the supplies as they come into the facility, we order through L.A Medical Supply but we do not personally don't do direct charge anything to families or residents. R1 , did have Home Health Services and when R1 became incontinent they ordered supplies from LA Medical Supply. Medi-cal/ Insurance pays for supplies. We do room and board, family have no charge that come directly to family for the adult brief or other supplies." Licensee stated "when we admit a resident we give family handbooks and policy information, and we provide supplies like briefs. Residents use Medi-cal programs most are on assisted living wavier program." LPA Calderon reviewed document for L.A Medical Supply - Incontinence supply prescription form for R1.

Regarding Allegation: Facility staff did not ensure that resident received their medication while in care.
5 out of 5 staff during interviews denied the above allegation and state that all residents take their medications, no issues. 12 out of 13 residents denied stated they all take medications and have no issues or know about residents that did not receive medications. R8 stated " yes, I get my medications and no issues." LPA Calderon interviewed 5 out 5 staff and 4 out of 5 staff and stated they denied above allegation and residents get medication and no incident on residents not receiving medication. LPA Calderon reviewed R1 Medication Record Log , Physician Orders and Facility Narrative Charting in regarding to medication discontinuation, treatment , evaluations and prescription orders.

Regarding Allegation: Facility staff restrained resident to a wheelchair while in care. 12 out of 13 residents stated they denied above allegation and they do not see residents getting tied down to wheelchair. R10 stated " I use wheelchair I do not get tied down , or not see others." R6 stated I use a wheel chair and no one ties me up and I do not see others getting tied up. 5 out of 5 staff denied any residents being tied down to a wheelchair. Administrator stated " No, I do not tie them to wheelchairs and do not see my staff do that. R1 was slipping occasionally off her wheelchair. Facility provided an accessory that is like a table that attaches to the wheelchair but it doesn't tie one down and did not tie R1 down. Due to R1 slipping on care family wanted to provide facility with a belt for R1 to get tied down. Facility refused and said it was a restraining device and that cannot use that. When slipped occurred for R1 facility provided supervision, family was around a lot or R1 would be in bed. R1 had weak balance and saw physicians for care.
Continuation on LIC9099C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20221115101026

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: 11/21/2022

NARRATIVE

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Regarding Allegation: Facility would not take resident back after discharges from hospital. 12 out of 13 residents have not heard or seen residents not being allowed to return after discharge from the hospital. R2 stated "No issues I came back after rehab." R4 stated " I have been hospitalized and they accept me back and no issues. " R11 stated " People go back and froward to the hospital." 5 out of 5 staff denied the above allegation and no do refuse residents from returning after hospital. Licensee Kim stated " we usually accept all residents back but it also depends on the care they need. R1 needed higher level of care and couldn't return just yet, we informed family of the steps to return." Tammie stated "Hospital wanted the resident to do skilled nursing problem or be on Hospice. Facility told family of R1, R1 may return only if on Hospice, family was not sure on what decision to make as they waited facility entered a resident on Hospice Care. Facility hit the limit of approved Hospice number for residents on Hospice Program, leaving no space for the R1 to be on Hospice by the time family made decision. Family didn't want R1 to go to a different facility. Therefore, facility could not accept resident due to Hospital orders of R1 needing higher level of care, like Skilled Nursing. Facility did give family member the option to reassessing R1 after going to Skilled Nursing first . LPA Calderon reviewed Facility Narrative Charting Documentation. It states on 10/06/22 R1 doctor recommended skilled nursing. LPA Calderon reviewed Unusual Incident Report dated 10/07/22 for R1 stating Good Samaritan Hospital called facility and stated R1 needs skilled nursing and that License stated R1 needs to go to skilled nursing facility and to return when R1 is ready.

Regarding Allegation: Resident is being illegally evicted from the facility. 5 out of 5 staff denied above allegation and did not distribute eviction notice to resident(s). Tammie Administrator stated " No it was not an eviction for R1, we never evicted R1 but family took it that way. R1 was in the Hospital and got transferred to Skilled Nursing Facility. LPA Calderon telephonically interviewed family member of R1, family member stated "No I didn't get a eviction notice I believe it was an eviction because hospital called to see if facility would accept R1 back and at first they said they had a bed available for Hospice admission but when we the family , made a decision after two weeks we were then told by Licensee Jean Kim no more beds available.

Regarding Allegation: Facility staff does not give residents adequate time to eat a meal. During the interviews 12 out of 13 residents denied allegation of not getting adequate time for meal time and stated they do not have a time frame or get taken food away after 30 minutes of eating. R4 stated when asked about getting a time frame for meals, "no we sit there and enjoy the meals, we are slow eaters."
Continuation on LIC9099C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20221115101026

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: 11/21/2022

NARRATIVE

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LPA Calderon interviewed 5 out of 5 staff during interviews staff denied allegation above and stated meal times aren't timed. Director Kim stated " We have food menu provided monthly, no time frame, but dinning room opens at 11:45 am till whenever."Administrator stated "Lunch starts at 11:40am and no specific time to end but some finish around 1 -2 pm depending. Caregivers and Medical technicians help those residents who need help with feeding." S2 stated " No time frame but even if it takes long , staff assist." LPA Calderon observed two dining room areas were residents were observed to eat at their own pace.

Regarding Allegation: Facility failed to notify residents responsible party of change of condition.
Interview with Administrator stated " R1 family member was notified about change of condition and any incidents, last hospitalization it states it on the Special Incident Report 10/7/2022 via phone call communication was provided to Family member of R1. LPA Calderon telephonically interviewed R1 family member and stated when asked if facility has communicated to about R1 changes of condition, family member stated "some what , communication verbally I would ask Tammie Administrator but Tammie wasn't aware of what was happening."

Based on LPA's observations, record review 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 Licensee Jean Kim.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

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