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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609314
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:33:39 PM


Document Has Been Signed on 09/26/2022 12:33 PM - It Cannot Be Edited

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: 4DATE:
09/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Rufina Eguchi, CaregiverTIME COMPLETED:
12:45 PM
NARRATIVE
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On 09/26/2022 Licensing Program Analyst (LPA) Troy Agard conducted a case management-deficiency visit. LPA met with Caregiver, Rufina Eguchi and explained the purpose of the visit.

During an investigation LPA was informed by the caregiver, who was informed by a representative, the Licensee and Administrator would not be available and able to assist in the investigation and obtain records due to a religious holiday. Caregiver stated Administration will not be available until Wednesday, 09/26/2022. Thus, leaving the facility without a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility in their absence.



California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview was conducted, and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
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 2


Document Has Been Signed on 09/26/2022 12:33 PM - It Cannot Be Edited

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: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
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...shall be on the premises a sufficient number of hours to permit ... When the administrator is not in the facility, there shall be coverage by a
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designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.... This requirement was not met as evidence by: Based on interview w/ caregiver, the facility will be without administration until Wednesday. This poses a potential health and safety risk to residents in care.
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Type B
09/28/2022
Section Cited

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87755 Inspection Authority of the Licensing Agency. (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).
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This requirement was not met as evidence by: an attempted reocord review. LPA was unable to gain access to records during an investigation due to administration or a designee being onsite or available by phone.
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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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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