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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603171
Report Date: 12/09/2023
Date Signed: 12/09/2023 12:47:00 PM

Document Has Been Signed on 12/09/2023 12:47 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EILAT'S MANOR IIFACILITY NUMBER:
198603171
ADMINISTRATOR:NAHUM, EILATFACILITY TYPE:
735
ADDRESS:1623 SHERBOURNE DRTELEPHONE:
(310) 309-0405
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 6DATE:
12/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Noame Leibov /ManagerTIME COMPLETED:
12:46 PM
NARRATIVE
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On 12/9/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Noame Leibov /Manager and the purpose of today’s visit was explained. The facility is licensed to operate for (6) age range 18 through 59 of which (6) can be non-ambulatory and (1) may be bedridden. Currently, the home has (6) clients.

This facility is located on the second floor of the building and consists of four (4) bedrooms, three (3) bathrooms, kitchen, dining area, living room (with balcony), and laundry room.

LPA Iniguez and manager toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 109.3F°, Bathroom #1 107.6°F, Bathroom #2 108.3F°, and Bathroom #3 101.3F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171
VISIT DATE: 12/09/2023
NARRATIVE
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility disaster drill was:10/18/2023.

LPA conducted a records review of (4) client records, (3) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page). Facility needs an age exception for R#1


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Noame Leibov /Manager.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023
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Document Has Been Signed on 12/09/2023 12:47 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/09/2023 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)(1)(4)

85068.4 Acceptance and Retention Limitations
(c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file:(1) Completed Functional Capabilities Assessment, required by Section 80069.2.
(2) Completed Needs and Services Plan, required by Section 85068.2. If one or more age-related care needs are identified by the provider or the referring source, the licensee shall ensure that the Needs and Services Plan specifies how such need(s) will be addressed.(3) Documentation of a medical assessment, signed by a physician, made within the last year. (4) A letter of support from the person's conservator with placement authority, if applicable.
(5) Letters of support, if any, from the person's placement officer, social worker, and/or mental health professional, if applicable, documenting that the Adult Residential Facility is the most appropriate setting for the person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review the licensee did not comply with the section cited above in having an extra client over 59 years old which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will ensure the facility does not have more than 50% of the total census clients over 59 years old. Licensee stated that she either removed one client and put them in another facility the licensee owns or she will request an age exception from the department. As POC, licensee will inform LPA via email about the desition she will take.

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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2023 12:47 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/09/2023 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in keeping cleaning supplies locked at all time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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 During this visit licensee removed cleaning supplies from bathroom sink and locked them away. Licensee will ensure all cleaning supplies are locked at all times. As plan of correction POC licensee will re-train staff on how to keep cleaning supplies locked at all times. A copy of this training will be sent to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2023 12:47 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/09/2023 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having a health screening in file for one of the carestaff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will ensure all staff has a health screening on file. As part of POC, licensee will submitt a copy of missing health screening to LPA via email before POC due date.
Type B
Section Cited
CCR
80066(b)(2)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (2) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above in not having a TB test for one of the carestaff on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will ensure all carestaff has a TB test on file. As part of POC, licensee will submitt a copy of missing TB test to LPA via email before POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/09/2023 12:47 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/09/2023 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in not having a TB test for one of the clients' files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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3
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Licensee will ensure all clients has a TB test on file at all time. As part of Plan of Correction-POC, licensee will provide to LPA via email a TB test or chest x-ray via email before POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


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