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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609314
Report Date: 01/27/2022
Date Signed: 02/07/2022 02:39:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
01/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Miriam RudesTIME COMPLETED:
04:30 PM
NARRATIVE
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SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2022
Section Cited

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87411 Personnel Requirements - General
(3) The training shall include, but not be limited to, the following: (c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter.
This requirement is not met as evidence by:
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Based on observation LPA did not observed current training records for Staff #1-2. This possess a potential health and safety risk to residents in care.

This posses a potential health and safety risk to residents in care.
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Type B
02/07/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidence by:
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During LPA's interview conducted with administrator and police officer. Administrator did not submit and incident report to LPA regarding R1's incident that took place prior to visit.
This posses a potential health and safety risk to residents in care.
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Administrator will provide incident reports and submit to LPA. Administrator will review Title 22 and provide a written statement that she read and understood the regulation and will submit to LPA by POC due date 2/7/2022.
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: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2022
Section Cited

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87405
Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities ..

This requirement is not met as evidence by:
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Based on observation and record reviews the Administrator Miriam Rudes did not have a current Administrator Certificate or an Administrator wavier on file.

This poses a potential health and safety risk to residents in care.
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Type B
02/07/2022
Section Cited

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87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance.. 3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...
This requirement is not met as evidence by:
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LPA observed bed rails on R#2's bed. LPA reviewed residents files and did not see an exception for R2 to have bed rails.

This poses a potential health and safety risk to residents 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: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3