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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609314
Report Date: 04/08/2021
Date Signed: 05/05/2021 01:15:25 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
09/23/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200923164049
FACILITY NAME:BEIT SHALOM GROUP LLCFACILITY NUMBER:
197609314
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1620 S SHERBOURNE DRIVETELEPHONE:
(213) 222-7598
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 5DATE:
04/08/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Miriam Rudes, AdminositratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff mismanaged resident's medications
Facility staff failed to seek resident timely medical care
Facility staff failed to communicate with resident's responsible party
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. l interviews with the Administrator Miriam and S#2, R#1 -R#3, W#1, and toured room for R#2, living room, and Kitchen. The LPA Soto obtained the following records: Face sheets, Medical noted for Dec, Jan, Feb, and March 2021, Pre-Appraisals, Physician's Report, Mars Logs for (June, July, August, and September -2020,) Mars logs for (January, February, and March 2021,) and Incident Reports 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: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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 6
Control Number 11-AS-20200923164049
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 GROUP LLC
FACILITY NUMBER: 197609314
VISIT DATE: 04/08/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following.
For Allegation – Facility staff mismanaged resident's medications. The interviews with S#2 stated that for the last 4/5 months medication was given timely. The months prior to October 2020, before the medication was not given. Interview with Administrator stated that for a couple months around midyear of 2020 medication was not being given to R#1, because insurance did not cover the medication. R#1 needed R#1’s medication because R#1 had stroke on December 2019 and it was a necessity for his care. Administrator was not trying to help R#1 get the mediation by other means. Case manager for R#1, was assigned to R#1 on August 2020, she managed to resolve the medication issue and R#1 began receiving R#1’s medication. The mars for June, July, August 2020 are signed as the medication was being given. Interviews with W#1, stated that administrator was not getting Medication for R#1 for couple months prior to her getting assigned R#1. She also stated that when she did manage to arrange medication for R#1, she had to call administrator several times during a span of a few days to have Administrator pick up R#1’s medication and never pick them up. Interviews with residents could not deny or verify statements, due to their neurological disorder and/or not available to be interviewed. The interviews with Administrator, S#2, W#1 and records reviews concurred with the above allegation.

Allegation #2 - Facility staff failed to seek resident timely medical care. Interviews with Administrator and S#2, stated that they did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke on December 2019, they still did not take them to doctor appointments. Administrator did not find other means to have R#1 see R#1’s PCP (Doctor.) Administrator did not updated Needs and Services plan. Interview with W#1, stated that the administrator never took R#1 to doctor appointments, even thought R#1 had medical. The Interviews with residents could not deny or verify statements, due to their neurological disorder and/or not available to be interviewed. The interviews with Administrator, S#2, and W#1 concurred with the above allegation.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20200923164049
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 GROUP LLC
FACILITY NUMBER: 197609314
VISIT DATE: 04/08/2021
NARRATIVE
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Allegation #3 - Facility staff failed to communicate with resident's responsible party. Interview with administrator, stated that she was working with the previous Case Manager and she was helping R#1. LPA Soto requesting previous email showing communication with previous Case Manager about medication, stroke, and missed doctor visits. Administrator never produced the emails and could not remember Case Managers name. Interview with W#1, stated she never had any communication with her and was not aware, if administrator had communication with the previous Case Manager. Interviews with S#2 and residents could not very or deny statements. The residents, due to their neurological disorder and/or not available to be interviewed and S#2 is just a care giver doesn't know anything about administration. The interviews with Administrator and W#1 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 allegations are 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: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20200923164049
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 GROUP LLC
FACILITY NUMBER: 197609314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2021
Section Cited
CCR
80075(a)
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80075(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.This was quirement was not met as evidence by:
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Adminstrator to create a plan detailing step that the administartor will take in the future to avoid having clients to go without medical care. Administrator to provide the paln to LPA by email or fax by 04/16/21.
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Based on obeservations and interviews They did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke, they still did not take them to doctor appointments. Which poses a potential health safety to persons in care.
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Type B
04/08/2021
Section Cited
CCR
80072(a)2
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T80072(a)2-to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This was requirement was not met as evidence by: Based on obeservations and interviews
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Administrator to create a plan detailing step that the administartor will take in the future to avoid having clients to go without medical care. Administrator to provide the paln to LPA by email or fax by 04/16/21.
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They did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke, they still did not take them to doctor appointments. 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: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20200923164049
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 GROUP LLC
FACILITY NUMBER: 197609314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2021
Section Cited
CCR
80075(b)5(B)
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80075(b)5(B) Once ordered by the physician the medication is given according to the physician's directions.This was quirement was not met as evidence by:
Based on obeservations and interviews for a couple months around midyear of 2020
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Adminstrator to create a plan detailing steps that the administartor will take in the future to avoid having clients to go without medication. Administrator to provide the paln to LPA by email or fax by 04/16/21.
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medication was not being given to R#1, because insurance did not cover the medication. Which poses a potential health, safety to persons in care.
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Type B
04/08/2021
Section Cited
CCR
85064(j)4
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85064(j)4 - Provision of, or insurance of the provision of, services to the clients, required by applicable law and regulation, including those services identified in the client's individual needs and services plans. This was quirement was not met as evidence by:
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Adminstrator to create a plan detailing step that the administartor will take in the future to avoid having clients to go without medical care. Administrator to provide the paln to LPA by email or fax by 04/16/21.
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Based on obeservations and interviewsthey did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke, they still did not take them to doctor appointments. 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: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20200923164049
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 GROUP LLC
FACILITY NUMBER: 197609314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2021
Section Cited
CCR
85068.3(a)
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85068.3(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.This was quirement was not met as evidence by:
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Adminstrator to create a plan detailing step that the administartor will take in the future to avoid having clients to go without medical care. Administrator to provide the paln to LPA by email or fax by 04/16/21.
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Based on observations and interviews R#1 had suffered a stroke. Which poses a potential health, safety to persons in care.
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Type B
04/08/2021
Section Cited
CCR
80061(d)(f)
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80061(d)(f) -The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.
This was quirement was not met as evidence by: Based on observations and interviews
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Adminstrator to create a plan detailing step that the administartor will take in the future to notify clients responsible party of any medical changes. Administrator to provide the paln to LPA by email or fax by 04/16/21.
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previous email showing communication with previous Case Manager about medication, stroke, and missed doctor visits. Administrator never produced the emails and could not remember Case Managers name. 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: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6