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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609314
Report Date: 01/06/2023
Date Signed: 01/06/2023 12:52:47 PM


Document Has Been Signed on 01/06/2023 12:52 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: 6DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH: Administrator, Miriam RudesTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA conducted risk assessment at the front door of the facility with Caregiver, Nancy Ogemba. Nancy stated, "No COVID-19 in the facility". LPA was met by staff, Eilat Nahum then later Administrator, Miriam Rudes joined us and the purpose of today’s visit was explained. The facility is for the elderly and licensed to serve 6 residents ages 60 and over. 5 Non-Ambulatory and 1 Bedridden only. Hospice Waiver for three. There are currently (6) Residents that are at the facility. The Facility is a single -story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, living room, kitchen and living room, laundry room, outdoor patio covered area.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.4 F and bathroom #2 115.0 F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there was enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

Continued on LIC 809.C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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


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
VISIT DATE: 01/06/2023
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Administrator, Miriam provided LPA with a copy of the facility Liability Insurance Quote.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

No deficiencies cited under California Code of Regulations Title 22,

Exit interview conducted and a copy of the report was provided to Administrator, Miriam Rudes

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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