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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608859
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:00:55 PM



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
04/15/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210415120420
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: DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Harrix ManuelTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff hit the resident.
INVESTIGATION FINDINGS:
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On 9/6/21 at Licensing Program Analyst (LPA) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent visit in order to render investigation findings for the above allegation. LPA met with Harrix Manuel, the Caregiver and the purpose of the visit was explained.

On 4/22/21, LPA Brown and LPM Hammond conducted a Health & Safety visit that consisted of the following: Toured the facility physical plants, LPA and LPM conducted interviews with Administrator and Staff #S1. LPA requested the following documentation: Resident & Staff Roster, Residents #1-2 files, Staff #1-3 records.

The investigation consisted of the following:

Staff hit the resident.

LIC 9099-C is on the next page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 2
Control Number 11-AS-20210415120420
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: 09/16/2021
NARRATIVE
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On 4/22/21, LPA interviewed the reporting party regarding the above allegation. RP stated resident #1 s was being hit on the shoulder by residents and staff. RP stated there were no injuries reported. RP stated R1 has limited speech but was able to make a mad gestured to show how was hit. On 4/22/21, LPA interviewed the Administrator regarding the above allegation. Administrator stated residents were not hit by other residents or staff. Administrator stated no one had address any concerns to her. On 5/11/21 LPA interviewed staff #1-2 and residents #2-3. Staff stated they did not see any residents being hit by residents or staff. LPA attempted to interview R1, but the resident was unable to verbally communicate. LPA interviewed residents #2-3 and they stated were not hit by residents or staff or did they see any other residents being hit. LPA was unable to interview resident #4 due to the resident unable to communicate.

Although the allegations are valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2