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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608859
Report Date: 04/14/2021
Date Signed: 04/28/2021 10:28:46 AM



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
10/20/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201020162034
FACILITY NAME:EILAT'S MANORFACILITY NUMBER:
197608859
ADMINISTRATOR:MIRIAM RUDESFACILITY TYPE:
740
ADDRESS:1621 S. SHERBOURNE DRIVETELEPHONE:
(310) 273-3133
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 5DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Miriam Rudes, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff do not supply resident with incontinence products
Facility staff do not answer residents call for assistance
Facility staff left resident in soiled clothing for an extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Miriam Rudes, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 03/18/21, LPA Soto interviewed the Administrator and conducted tele-virtual interviews with S#2, S#3, R#1 - R#3. LPA also toured the facility: Living room and dining room. On 03/18/21, LPA Soto also requested copies of the following documents: Face sheets, Medication logs, Pre-Appraisals, Physician's Report, and Appraisal/Needs and Services Plan, Bowel Movement Log for (October, November, and December 2020.) Admissions Agreement for R#1 - R#3.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 5
Control Number 11-AS-20201020162034
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: EILAT'S MANOR
FACILITY NUMBER: 197608859
VISIT DATE: 04/14/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following:
For Allegation #2 - Staff did not provide diapers for resident. Interview with administrator, stated that R#1 was supposed to paying for R#1 incontinence products, but she had waived that fee for R#1. After, Covid administrator could not afford to waive it anymore. R#1 was asked to pay for R#1’s own incontinence products. Interviews with R#1, could not remember if R#1 was paying or not paying for R#1 own incontinence products. Interview with W#1, stated that facility should be paying for incontinence products. Interviews with S#2 &S#3, they stated they weren’t aware if R#1, who paid for R#1 incontinence products. Interviews with R#1 – R#3, LPA Soto could not interview residents, due to the residents not available to be interviewed at the time of visit. LPA Soto reviewed R#1’s admission Agreement, the documents shows that R#1 is responsible for paying for incontinence products. Interviews conducted did not concur with the above allegation.

For Allegation #3 – Staff did not assist resident. Interviews with Administrator and staff stated that they immediately go to the residents who ask for assistance. They help them with whatever they need. Interviews with R#1 and W#1, stated that R#1 on a couple of occasions has been left unattended without help for several hours. Interviews with R#1 – R#3, LPA Soto could not interview residents, due to the residents not available to be interviewed at the time of visit. Interviews conducted did not concur with the above allegation.

For Allegation #4 – Staff left resident in soiled diaper for a long period of time. Interviews with Administrator and staff stated that they check the resident’s with incontinence every 2/3 hours. If needed, they change their diaper. Interviews with R#1 and W#1, stated that R#1 on a couple of occasions has been left with soiled diaper for several hours at night. Interviews with R#1 – R#3, LPA Soto could not interview residents, due to the residents not available to be interviewed at the time of visit. LPA Soto reviewed the bowel movement log and it showed that staff is changing residents every 2/3 hours and as residents need it. Interviews and records reviewed did not concur with the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

A tele-visit exit interview was conducted with Miriam Rudes, Administrator, and a hard copy was provided via email for signature.



SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/20/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201020162034

FACILITY NAME:EILAT'S MANORFACILITY NUMBER:
197608859
ADMINISTRATOR:MIRIAM RUDESFACILITY TYPE:
740
ADDRESS:1621 S. SHERBOURNE DRIVETELEPHONE:
(310) 273-3133
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 5DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Miriam Rudes, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Resident was admitted to the facility against their will.
INVESTIGATION FINDINGS:
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4
5
6
7
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10
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12
13
Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Miriam Rudes, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 03/18/21, LPA Soto interviewed the Administrator and conducted tele-virtual interviews with S#2, S#3, R#1 - R#3. LPA also toured the facility: Living room, dining room and C#3 room. On 03/18/21, LPA Soto also requested copies of the following documents: Face sheets, Medication logs, Pre-Appraisals, Physician's Report, and Appraisal/Needs and Services Plan, Bowel Movement Log for (October, November, and December 2020.) Admissions Agreement for R#1 - R#3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20201020162034
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: EILAT'S MANOR
FACILITY NUMBER: 197608859
VISIT DATE: 04/14/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following:

For Allegation #1 – Staff relocated resident without permission. Interview with Administrator, she stated that R#1 did agree to change facilities. She spoke to R#1 about the other facility (Eilat’s Manor) how Much R#1 would like to live there and R#1, would still have everything R#1 had there at Beit Shalom. The bedroom and shower would bigger to accommodate R#1 and wheelchair. According to Administrator R#1 agreed to try It. LPA Soto requested copies of form signed where R#1 agreed to the change. Administrator failed to provide the form to LPA Soto. Interviews with R#1 and W#1, stated that R#1 did not want to move, R#1 wanted to stay at Beit Shalom. Interviews with S#2 & S#3, stated that they were not aware of anyone moving facilities without their consent. Interviews with R#1 – R#3, LPA Soto could not interview residents, due to the residents not available to interview at the time of visit. The interviews conducted concurred with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

Telephonic exit interview was conducted with Miriam Rudes, and a hard copy was provided via email for signature and Appeal Rights provided

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20201020162034
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: EILAT'S MANOR
FACILITY NUMBER: 197608859
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2021
Section Cited
CCR
87468.1(3)
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87468.1(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met by:
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Administrator to create plan as to how they will meet this requirement in the future by 05/04/21 send correction by email, fax, and/or mail.
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Based on observations nad interviews resident transferred rooms without permission.
which poses a potential health, safety to persons 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: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5