197609314-9-11-2023-11-AS-UCOL-CYQUE8-20231221143042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609314
Report Date: 09/11/2023
Date Signed: 09/11/2023 09:51:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/01/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230901112957

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:	09/11/2023
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Miriam Rudes, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff is disclosing resident sensitive information to third parties
Facility staff fails to follow infection protocols

INVESTIGATION FINDINGS:

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On 09/11/2023 Licensing Program Analyst (LPA) Mario Leon conducted an unanounced complaint visit at the above facility. LPA was met by LUCY SETIAWAN (Staff two - S2), caregiver, and later by MIRIAM RUDES (Staff one - S1), Administrator, and the purpose of the visit was explained.

The investigation consisted of the following:

LPA Leon toured the facility inside and out, interviewed three (3) staff (S1-S3) and four (4) residents (R1-R4). LPA also interviewed one witness (W1). LPA Leon requested and reviewed facility documents which included resident roster, staff roster, infection control plan and doctor's orders.

The investigation revealed the following:
Regarding the allegation: Facility staff is disclosing resident sensitive information to third parties.
It has been alleged that the facility staff are disclosing resident sensitive information to third parties. LPA Leon interviewed three (3) staff members and all three (3) have denied the allegation. LPA Leon interviewed four (4) residents and three (3) out of four (4) residents have denied the allegation. LPA Leon interviewed one witness who was also unaware of the allegation.
According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstatiated.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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-20230901112957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM GROUP LLC	FACILITY NUMBER: 197609314
	VISIT DATE: 09/11/2023

NARRATIVE

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Regarding the allegation: Facility staff fails to follow infection protocols.
It has been alleged that the facility staff are failing to follow the infection control protocol. LPA observed one bath aide fully donned in gown, pants, booties, gloves and hair net conducting a bathing session on one resident. LPA also observed all staff wearing face masks and all staff using separate nitrile gloves while conducting work with different residents. LPA interviewed three staff (S1-S3) and one witness (W1). All staff have denied the allegation and have provided sufficient information to follow infection control policy. Therefore three (3) out of four (4) interviewees have not supported this allegation. LPA Leon observed the infection control policies for the facility and have observed one infected resident (R1), bedridden, isolated within their room. According to S1, the facility does not allow any visitors through 09/11/23 and all six (6) residents are currently using doctor's ordered medication to prevent further spread of the infection to the remainder of the community.
According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstatiated.

An exit interview was held with Administrator, Miriam Rudes, and a copy of this report has been provided via email.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

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