197609314-12-6-2021-11-AS-JHAD-C9XNX5-20211222095034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609314
Report Date: 11/16/2021
Date Signed: 12/06/2021 09:34:58 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
07/08/2020 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200708111651

FACILITY NAME:	BEIT SHALOM GROUP LLC		FACILITY NUMBER:	197609314
ADMINISTRATOR:	RUDES, MIRIAM		FACILITY TYPE:	740
ADDRESS:	1620 S SHERBOURNE DRIVE		TELEPHONE:	(213) 222-7598
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 6	DATE:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	MIriam Rudes		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff neglect led to hospitalization of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. LPA met with Miriam Rudes, the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 06/16/2020 Licensing Program Analyst (LPA) Pamela Bunker interviewed 3 staff and 3 residents. LPA Bunker requested copies of supporting documents. On 08/31/2021 LPA Coronel conducted a tour of the facility, interviewed the administrator, 2 staff, 6 out of 6 residents and 2 witnesses. LPA Coronel requested client, staff and facility records. On 09/08/2021 LPA Coronel Conducted record Reviews. On 09/23/2021 LPA interviewed staff S3. On 10/19/2021 LPA Coronel submitted a service request for the Departments Investigation Bureau to obtain client C1’s Hospital Medical Records.

The investigation revealed the following: Regarding the allegation: “Staff neglect led to hospitalization of resident.” On 07/20/2020 the department received information that R1 was observed having an infection, high temperature, pus in their Foley catheter and had feces on them.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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-20200708111651

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: 11/16/2021

NARRATIVE

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On 08/31/2021 3 out of 6 clients interviewed stated that they got helped by staff whenever they needed it, client R3 stated “Yes, (I get helped) immediately.” 1 out of 6 clients R4 did not provide an answer when asked 1 out of 6 clients was neutral, R5 stated they “I never really needed help.” and 1 out of 6 clients stated they did not get helped by staff whenever they needed help. Caregiver S1 stated “R1 did not have a catheter, R1 always peed in their diapers... I was not here when they called 911, R1 was no longer here when I came back." S2 stated “I was not working here yet." The administrator stated ‘Prior to the paramedics arriving, I told former caregiver S3 not to touch or move R1. The paramedics then told me that they will make a report about R1 having feces when they got here." Witness W1 stated “Due to it being the peak of COVID-19 at the time, I did not see R1 during their stay at Beit Shalom." On 09/08/2021 LPA Coronel did not observe records of C1’s Foley Catheter. On 09/23/2021 S3 stated “C1 does not have Catheter Care Records." On 11/12/2021 Special Investigator Assistant Veronica Padilla reported that Olympia Medical Center and Kaiser Hospital were not able to provide any Hospital Medical Records based on C1’s information on file. Regarding the allegation: “Staff neglect led to hospitalization of resident.”; 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.

No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to Miriam Rudes.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

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