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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608630
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:58:18 PM

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: DATE:
01/27/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Harrix Manuel and Leah Argana GoldsmithTIME COMPLETED:
04:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Case Management – Health and Safety Check visit. LPA was met by staff Harrix Manuel and Leah Argana Goldsmith and the purpose of today’s visit was explained. The facility is licensed to serve up to 6 non-ambulatory residents, of which 1 may be bedridden. The facility has a hospice waiver for 1. There are currently 6 residents in placement. All 6 clients are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 4 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor /outdoor activity area and laundry.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 112.8 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During todays visit LPA observed that the door bedroom# 2 is being obstructed by resident R3's bed, the walk way in the west side of the facility is being obstructed by 6 wheelchairs and a picket gate and the front and back doors have latch type locks installed more than 5 feet high. LPA also observed presence of former resident F1's medications kept with currents residents centrally stored medications. During record review an active administrator certificate was not observed for the administrator Miriam Rudes which is not in compliance with PIN 21-24-CCLD. During review of the facilities staff roster LPA observed that Eilat Nahum is indicated as the administrator.

During today’s visit there were deficiencies observed, California Code of regulation title 22 Division 6 Chapter 8 is being cited, please see LIC809D.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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 4
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
VISIT DATE: 01/27/2022
NARRATIVE
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors. LPA observed staff were wearing face coverings and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

Exit interview held and plans of correction were developed. A copy of this report and appeals rights was provide.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2022
Section Cited

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Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement was not met as evidenced by:
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Based from LPA observation, the licensee failed to ensure thatAll outdoor and indoor passageways are kept free of obstruction. the emergency exit in Bedroom# 2, the walk way in the west side of the facility and the front and back doors are obstructed, which a poses a potential health and safety risk to residents in care.
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Type B
02/10/2022
Section Cited

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Incidental Medical and Dental Care. Prescription medications which are not taken with the resident upon termination of services... shall be destroyed in the facility ...resident. Both...following: Name of the resident. The prescription..pharmacy.The drug name, strength and quantity destroyed. The date of destruction.
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This requirement was not met as evidenced by: Based from LPA observatio and record reviews the licensee failed to ensure that Prescription medications which are not taken with the resident upon termination of services are destroyed which a poses a potential health and 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: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2022
Section Cited

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Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. The ...person. The ... section. When.. section. The ... documentation.
This requirement was not met as evidenced by:
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Based on observation and record reviews the licensee failed to ensure that the facility has a certified administrator, during record review an active administrator certificate was not observed for the administrator Miriam Rudes which poses a potential health and safety risk to residents in care.
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Type B
02/10/2022
Section Cited

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Reporting Requirements. The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: Date he/she assumed his/her position.
This requirement was not met as evidenced by:
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Based on record reviews the licensee failed to ensure that the Department is notified within 30 days of hiring of a new administrator, during review of the facilities staff roster LPA observed that Miriam Rudes is not indicated as the administrator, which poses a potential health and 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: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4