197608859-12-12-2021-11-AS-MVAO-C9WU7P-20211221142012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608859
Report Date: 12/09/2021
Date Signed: 12/12/2021 11:20:29 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
12/17/2020 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201217143740

FACILITY NAME:	EILAT'S MANOR		FACILITY NUMBER:	197608859
ADMINISTRATOR:	MIRIAM RUDES		FACILITY TYPE:	740
ADDRESS:	1621 S. SHERBOURNE DRIVE		TELEPHONE:	(310) 273-3133
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 5	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	10:34 AM
MET WITH:	Office Manager - Naome Leibov		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff allowed resident's to wander away from the facility.
Facility not administering medications as prescribed.

INVESTIGATION FINDINGS:

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On 12/24/20 Licensing Program Analyst, LPA/Don Senaha initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via zoom with Eilat Nahum/Administrator and staff (S1).

On 12/09/2021 Licensing Program Analyst (LPA) Don Senaha conducted a subsequent unannounced complaint visit to this facility and met with House Manager Naome Leibov. The purpose of this visit is to investigate and deliver the findings of the investigation completed.

The investigation consisted of the following: LPA requested resident roster, staff roster and other service documents on 12/24/2020. On 12/09/21, LPA requested updated resident roster and staff roster and conducted interviews with residents (R1-R5), (S1-S3) and witness (W1-W2). Resident (R4) was admitted to the facility yesterday 12/08/21 at around 6pm and was sleeping. Resident (R5) declined to be interviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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-20201217143740

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: 12/09/2021

NARRATIVE

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A plant inspection of the facility was conducted on 12/20/2020 virtually and in person on 12/09/2021.

Investigation revealed:

Allegation: Staff allowed residents to wander away from the facility.

It is alleged the staff allowed residents to wander away from the facility. Residents (R1-R3) did not have any concerns regarding the care and supervision being provided to them by the staff. Resident (R1) is non-ambulatory and stated she requires staff to help push on her chair to go outside. Resident (R2-R3) stated they do leave the facility but at their own will and let the staff know anytime they leave the facility. Staff (S1-S3) stated they have never had a missing/AWOL resident. LPA spoke to witness (W1) and he stated he has never seen or had an issue with resident (R6) wandering away from the facility. LPA spoke to witness (W2) and she stated there has been no issue of “getting lost” and staff follows resident (R5) if he goes outside. LPA did not see any incidents reported regarding a resident ever missing/AWOL.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated

Allegation: Facility not administering medications as prescribed.

It is alleged the facility is not administering medications as prescribed. Residents (R1-R2) stated they have not had an issue with medications being administered. Residents (R1-R2) stated they have never missed taking their medications. Staff (S1) stated there has been medication training for each staff. Staff (S1) stated staff (S1) monitors/audits the medications administered for all staff for the facility daily. Staff (S1) stated staff (S1) ensures medications are being given as prescribed and the Medication Administration Records (MAR) are being kept up to date. LPA spoke to witness (W1) and he stated there has never been an issue with medications and the facility has the meds under lock and key. LPA spoke to witness (W2) and she stated no issues with medications as prescribed. LPA received medication training logs for staff. LPA reviewed current MAR and found no issues.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20201217143740

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: 12/09/2021

NARRATIVE

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Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated

An exit interview was conducted with House Manager Naome Leibov and a hard copy was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC9099 (FAS) - (06/04)

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