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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608630
Report Date: 08/19/2021
Date Signed: 09/01/2021 11:28:08 AM

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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BEIT SHALOMFACILITY NUMBER:
197608630
ADMINISTRATOR:MIRIAM RUDESFACILITY TYPE:
740
ADDRESS:8537 PICKFORD STREETTELEPHONE:
(310) 309-0405
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 6DATE:
08/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Naomi Leibov-House ManagerTIME COMPLETED:
03:00 PM
NARRATIVE
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Case Management incident to conduct a Health & Safety check to follow up on an incident regarding a resident being illegally evicted from the facility. LPA explained the purpose of today’s visit.

The Resident is a Department of Health Services client. Resident is now homeless due to the eviction. On 8/19/21 LPA spoke to the administrator and house manager and they both were unaware of the eviction procedure outline in Title 22.

On 8/19/21 LPA Brown issued deficiency cited on California Code of regulation title 22 Division 6 Chapter 8,

LIC 809-D is on the next Page
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM
FACILITY NUMBER: 197608630
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited

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87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement was not met as evidence by:
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Based on interviews conducted Administrator did was aware of eviction procedures outlined in Title 22. Administrator should have the knowledge to follow administrator duties.
This poses and immediate or potential risk health & Safety risk to residents 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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