197609314-10-3-2022-11-AS-MVAO-CKDPCR-20221020111222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609314
Report Date: 10/03/2022
Date Signed: 10/03/2022 03:16:05 PM

Unsubstantiated

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
09/16/2022 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220916163352

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: 4	DATE:	10/03/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Leah Goldsmith, Caregiver		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff threw water on resident while in care.
Staff yelled at resident in care.

INVESTIGATION FINDINGS:

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On 10/03/2022, Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to address the allegations listed above. LPA Agard met with Leah Goldsmith, Caregiver and explained the purpose of this visit is to deliver findings.

The investigation consisted of the following: LPA Agard conducted a tour of the facility grounds. The facility is a single story family style dwelling that consist of 3 bedrooms and 2 bathrooms, living room, kitchen, laundry room and outside shaded patio in front. The facility is licensed for 6 individuals. LPA interviewed staff, and residents, and reviewed records. LPA Agard requested the following documents, which were received by the due date: 1) Staff and Resident roster, 2) incident reports from the last 30 days. 3) Copy of R1’s file.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

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-20220916163352

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: 10/03/2022

NARRATIVE

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The investigation revealed the following: Regarding the allegation: Staff threw water on resident while in care. “It’s being alleged a staff threw water in a residents face.” LPA Agard attempted interviews with 4 out of 5 residents in total. 3 out of 5 denied the allegation to be true. R1 was unavailable for an interview. R2 was unable to participate due to their cognitive abilities. R3 states, “they are very nice to me here and never observed a staff throwing things. R4 states, “never seen anyone throwing anything let alone water.” R5 denied the allegation. “No”.

During interviews with the staff, LPA interviewed 2 out of 7 staff in total. 2 out of 2 denied the allegation to be true. S1 states R1 used to live here but doesn’t know where they are since they left for the hospital. No one ever threw water at R1. S2 states, “the water thing is a lie.”

The investigation revealed the following: Regarding the allegation: Staff yelled at resident in care. “It’s being alleged that a staff yelled at a resident in care.” 3 out of 5 denied the allegation to be true. R1 was unavailable for an interview. R2 was unable to participate due to their cognitive abilities. R3 states, I’ve never overheard a staff yelling. R4 states, “staff are well behaved. I hear voices talking loudly and laughing but haven’t seen anyone yelling.” R5 states, “no, none of that here.”

During interviews with the staff, LPA interviewed 2 out of 7 staff in total. 2 out of 2 denied the allegation to be true. S1 states, “no staff ever yelled at R1. No sir!’ S2 states, “never, never.”

LPA Agard reviewed the following records: A staff roster dated for October 2022; all staff interviewed match roster. LPA reviewed a resident roster dated for July 2022, all residents match with roster. LPA reviewed incident reports from the past 60 days. No reports, reporting any residents that experienced verbal or physical abuse by a staff was observed. LPA reviewed R1’s file and tried to make contact with former resident and next of kin. LPA was unsuccessful.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

LIC9099 (FAS) - (06/04)

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