197608859-5-3-2022-11-AS-MVAO-CFLR8D-20220621124744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608859
Report Date: 05/03/2022
Date Signed: 05/03/2022 04:15:53 PM

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220425152124

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: 4	DATE:	05/03/2022
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Naome Leibov		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility did not issue refund to resident or resident's representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint investigation at the above facility. LPA spoke with facility staff via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegations listed above and was allowed entry to the facility.

The investigation consisted of the following: On 5/3/2022 LPA Cifuentes spoke with Administrator Eliat Nahume and staff Naome Leibov. LPA toured the facility grounds, reviewed facility files and requested and received copies of documents pertinent to the investigation. LPA Cifuentes interviewed (S1-S4), residents (R2-R5) and witnesses (W1-W2).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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-20220425152124

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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR	FACILITY NUMBER: 197608859
	VISIT DATE: 05/03/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Facility did not issue refund to resident or resident's representative

It is alleged that facility staff did not issue a refund to a resident or their representative. LPA spoke with staff Naome Leibov, who stated facility refund policy is upon death of resident or with thirty days’ notice given to vacate. LPA reviewed facility records and noted that out of those reviewed, three did not have any details filled out regarding refund policy but were signed by residents/representatives. Review of facility files also showed that a preadmission's policy was being charged but a written statement detailing pre-admission costs, stating the fee is refundable and describing those refund options was not found. LPA spoke with residents (R2-R5) regarding the allegation. Two were unable to answer due to diagnosis, but the other two stated they did not know anything about facilities refund policies. LPA spoke with staff (S1-S4) regarding allegations. Of the staff questioned, two stated they did not know facility refund polices, and the other two stated refund policy is upon death of resident or with thirty days’ notice given to vacate. LPA interviewed witnesses (W1-W2) regarding the allegation and both stated the facility refund policies were not clear.

Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. Records review of admissions agreement and supporting paperwork does not offer residents or their representatives a written statement detailing pre-admission costs, stating the fee is refundable or describe those refund options.

Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.

Exit interview conducted, appeal rights were discussed, and a copy of this report and appeal rights were provided to Jomar Fernando.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220425152124

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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR	FACILITY NUMBER: 197608859
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2022 Section Cited CCR 87505(g)(C)(1)	1 2 3 4 5 6 7	Admissions Agreement If a licensee charges a preadmission fee the licensee must provide the applicant...a written...statement describing all costs associated with...preadmission fee charges...stating that the preadmission fee is refundable...describing conditions for the refund This requirement was not as evidenced by:	1 2 3 4 5 6 7	Licensee will amend admissions agreement to include a written statement detailing preadmissions fee charges, stating fee is refundable and outlining conditions for the refund. Revised admissions agreement is due to CCLD via fax by POC due date.
	8 9 10 11 12 13 14	During records review on 5/3/2022, LPA did not observe any written statements provided to residents or their applicants detailing preadmissions fees. This is a potential safety risk to the residents in care	8 9 10 11 12 13 14
Type B 05/31/2022 Section Cited CCR 87505(g)(5)(E)(1)(b)	1 2 3 4 5 6 7	Admissions Agreement Preadmission fees shall be refunded according to the following...: A 100 percent refund of a preadmission fee shall be provided to an applicant or...representative if: The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions.	1 2 3 4 5 6 7	Licensee will provide R1 or thier representative with a 100 percent refund of preadmission fee and confirmation will be submitted to CCLD via fax by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: During records review on 5/22/2022 it was noted that R1's application noted a pre-admissions fee but did not offer details as required by regulation. This poses a potential risk to residents in care.	8 9 10 11 12 13 14

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC9099 (FAS) - (06/04)

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