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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608630
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:54:38 PM


Document Has Been Signed on 04/01/2022 02:54 PM - 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 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: 0DATE:
04/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eilat NahumTIME COMPLETED:
12:30 PM
NARRATIVE
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On 04/01/2022 Licensing Program Analyst (LPA) and Antonia Alvizar and Licensing Program Manager (LPM) Ulysses Coronel conducted a Case Management- Other to the above facility and met with Eilat Nahum Administrator.

On 03/29/2022 the department received information that this facility needed to relocate the residents. Due to the facility's lease has expired and property owner refusal to renew the lease.

During today's visit LPA and LPM conducted a tour of the facility and did not observe any staff or residents present at the facility. The licensee stated that the facility is no longer in operation as of 03/30/2022, 1 of 3 residents (R1) was relocated to EILAT'S MANOR 197608859 and 2 of 3 residents (R2 & R3) were relocated to MINI MANOR HOME 198603279.

There were deficiencies observed, California Code of regulation title 22 Division 6 Chapter 8 is being cited, please see LIC809D.

An exit interview was conducted. Plans of corrections were developed.

A copy of this report and Appeals Rights were provided to Eilat Nahum, Licensee.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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Document Has Been Signed on 04/01/2022 02:54 PM - 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 DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BEIT SHALOM
FACILITY NUMBER: 197608630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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87211(d)(1) Reporting Requirements. The licensee shall notify the Department..., in writing within two business days of any of the following specified events, or knowledge thereof: A notice of default, notice of trustee’s sale, or any other indication of foreclosure is issued on the property. This requirement was not met as evidenced by:
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Based on record reviews and interviews conducted the licensee failed to ensure that the Department was notified in writing within two business days of the property lease expiring on 02/28/2022, which poses a potential health, safety and personal rights risk to residents in care.
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Type B
04/02/2022
Section Cited

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87224(5)(A)Eviction Procedures. The licensee may... (5). Thirty (30) days written notice...is required except as otherwise specified ... (5). Change of use of the facility. The licensee may, upon no less than... (60) days written notice, evict a resident due to change of use of the facility.
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This requirement was not met as evidenced by: Based on record reviews and interviews condcuted the licensee failed to ensure that the residents were evicted no less than 60 days after being given written notices, which poses a potential health, safety and personal rights 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: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
LIC809 (FAS) - (06/04)
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