197608630-8-20-2021-11-AS-MVAO-C6EVGF-20210831162527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608630
Report Date: 08/19/2021
Date Signed: 08/20/2021 07:59:06 AM

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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210812145557

FACILITY NAME:	BEIT SHALOM		FACILITY NUMBER:	197608630
ADMINISTRATOR:	MIRIAM RUDES		FACILITY TYPE:	740
ADDRESS:	8537 PICKFORD STREET		TELEPHONE:	(310) 309-0405
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 6	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Eliat Nahum		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martessa Brown, conducted a visit to initiate a complaint investigation for the above allegation. LPA met with Administrator Eilat Nahum and Naomi Leibov House Manager and the purpose of today visit was explained.

During today’s visit investigation consisted of the following: On 8/19/21 LPA conducted a 10-day health & safety check visit. LPA conducted Interview with administrator, House Manager, staff #1. LPA toured the physical plant and reviewed resident #1 records: admission agreement, physician report, needs & service and emergency contact.

Investigation revealed the following:
Illegal Eviction

LIC 9099-C is on the next page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210812145557

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM	FACILITY NUMBER: 197608630
	VISIT DATE: 08/19/2021

NARRATIVE

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On 8/19/21, LPA conducted interview with administrator. She stated that R1 has been leaving the facility but will come back intoxicated. She stated R1 told staff she was leaving and not returning and took some belongings. She stated R1 was gone for 15 days. Administrator could not remember the date left. She stated her belongings were packed up and were put outside in the shed. She stated did not give R1 an eviction notices due to the policy of Department of Health Service (DHS). She stated DHS informed her if a resident was gone for 3 days or more they can fill out an exit slip to depart from the facility. Administrator stated was unaware R1 had to be evicted. LPA interviewed House Manger she stated R1 would have a visitor to come visit and she believe and that’s when she stated was leaving. She stated R1 told staff S1 that she was leaving and not returning. She stated R1 was gone for 15 days and then emailed an exit slip to DHS. She stated the policy from DHS stated was to complete an exit slip if resident has left 3 or more days. She stated staff 1 packed all belongings and put in the shed outside. She stated was not aware if residents were DHS client they still had to do an eviction notice according to DHS. LPA interview staff #1 she stated, R1 would always leave and come back drunk. S1 stated R1 told her she was leaving with friend. She stated R1 was gone for a week and then came back intoxicated. She stated had told R1 she is no longer living here, and her belongings were outside in the shed.

Substantiated: Based on Investigators interviews which were conducted with Administrator, House Manager, staff and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

An exit interview was conducted with Naomi Leibov, House Manager and a hard copy was provided and Appeal Rights provided.

See LIC 9009-D on the next page.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210812145557

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 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)
Request Denied Type B 08/31/2021 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 paragraph (5) This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator will review the eviction procedures outline in Title 22 to ensure of eviction process. Administrator will send a statement that she read and understood regulation 87224 (a) to LPA's attention by POC due date 8/31/21.
	8 9 10 11 12 13 14	Based on LPA's interviews conducted administrator and staff. Administrator did not evict R1 properly and follow Title 22 eviction policy and this poses a immediate or potential Health & Safety risk to residence in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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