Beit Shalom

Allegation investigated: Staff engaged in a verbal altercation in the presence of residents. Staff did not dispense medications as prescribed.

On 09/03/2026, Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced Complaint Visit to the facility listed above. LPA met with staff members and spoke by phone with Administrator (A1), Shimmy Bayar, and explained the purpose of today’s visit. The investigation consisted of the following: LPA conducted a facility inspection, interviewed three staff members (S1-S3), Administrators (A1, A2), and spoke with three residents (R2-R4). The LPA also received and reviewed several pertinent documents related to the investigation. These included the Staff Roster, Resident Roster, Admission Agreement, Addendum on Resident Rights, Physician’s Report, Physician’s Orders, Needs and Service Plan, Identification and Emergency Information, Personal Rights for Residential Care Facilities for the Elderly, Visitor Sign-In Logs from 08/30/2026, to 08/31/2026. A New Power of Attorney (POA) dated 03/31/2026, a Physician’s note dated 05/18/2026, and a Police Report dated 08/31/2026. LPA attempted to interview R1; due to R1 health condition, R1 was not able to answer the questions. LPA also attempted to interview the Long-Term Care Ombudsman (LTCO). Unsubstantiated Allegation #1: Staff engaged in a verbal altercation in the presence of residents. The complaint alleged that on 08/31/26, facility staff engaged in a verbal altercation in the presence of resident #1 (R1). On 09/03/2026, the LPA Richard interviewed the Administrator (A1) by phone regarding the altercation in the presence of the resident. A1 denied the allegation and stated that the Witness (W1) was the one engaging in the verbal altercation inside the room, and W1 then pushed A2 against the door, where A2 almost fell. The staff called 911. On the same day, the LPA interviewed the Administrator (A2), who stated that around 5:30 pm, A2 arrived at the facility and asked W1 about the medications that were not given; W1 started to yell, pushed A2 against the door, and A2 almost fell. Staff then called the police, who arrested W1 and removed W1 from the facility. At the same time, the LPA interviewed three staff members (S1-S3), who stated that staff do not engage in a verbal altercation when a resident has a guest in their room. They also stated that W1 comes to the facility every day, but staff are not to enter inside R1's room unless it is time for R1's medications. LPA interviewed three residents (R2-R4), who all denied that staff would engage in a verbal altercation in their presence. The staff is very considerate. Additionally, LPA interviewed a family member witness (W2), who denied the allegation and stated that staff treats R1's guest and R1 with respect. W2 also stated that staff goes above and beyond to help R1 with all of R1's needs. LPA interviewed the (LTCO), who stated that (LTCO) does not have permission to discuss R1 with LPA, but R1 was okay. Report continued on LIC9099C On September 02, 2026, LPA reviewed the facility records, including a police report filed with the Los Angeles Police Department (dated 08/31/2026 at 5:15 pm) by A2, which confirmed that A2 was allegedly pushed against the door by W1. W1 was arrested for battery, but no visible injuries. During the investigation, LPA could not find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated. Allegation #2: Staff did not dispense medications as prescribed. The complaint alleged that staff did not dispense medications as prescribed when questioned about administering R1's medications correctly, and that staff called the police. On September 03, 2026, the LPA interviewed the Administrator (A2), who denied the allegation and stated that staff dispense residents' medications as prescribed by the doctor. A2 also stated that they called the police because the witness, W1, pushed A2 against the door, almost causing A2 to fall. After the police arrived, W1 was arrested for battery. At the same time, the LPA interviewed three staff members (S1-S3), all of whom denied the allegations and stated that medications are given to residents on time, as prescribed by the doctor, with the residents' names, dates of birth, doses, what time, and how often they are to be given. They also stated that they would not administer the wrong medications to R1, since R1's medications are organized in a bubble pack, making them easy to identify. Report Continued on LIC9099C On September 03, 2026, the LPA interviewed three residents (R2-R4), who denied the allegations and stated that staff always provide their medications on time. R2 and R3 said this is the best place for them to live and praised the staff as very gracious and considerate. They reported no problems with their medications. The LPA also spoke with a family member, W2, who also denied the allegations. LPA interviewed the (LTCO), who stated that (LTCO) does not have permission to discuss R1 with LPA, but R1 was okay. On September 03, 2026, LPA reviewed the facility's Medication Administration Records (MARs) for resident R1 and found no discrepancies in the MARs or the Bubble Pack. LPA also reviewed the Los Angeles Police Department card (dated 08/31/2026) and confirmed that they were responding to a call involving battery and that the witness, W1, was arrested for battery. During the investigation, LPA could not find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to staff member Putri Rahayu.the state’s words, verbatim · CDSS document, Sep 3, 2026 · control 11-AS-20260901083446

Allegation investigated: Facility will not release resident records to authorized representative. Staff physically abused resident in care.

On 05/06/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted a complaint investigation visit at the facility and met with Administrator Shimon Bayar. The investigation consisted of the following: The Department interviewed four (4) staff members (S1-S4), interviewed five (5) residents (R1-R5), interviewed Witness (W1), conducted observations of the facility environment, and reviewed records including LIC 601, LIC 602, Admission Agreement, Durable Power of Attorney for Health Care, Medication Administration Records (MARs), daily care flow sheets, internal facility notes, and text message communications between the facility and resident representative. The investigation revealed the following: Regarding the allegation, “Facility will not release resident records to authorized representative,” it was alleged that the facility failed to provide requested resident-related information to (W1). Please see rerport continuation on (LIC9099-C) Unsubstantiated Interview with (W1) revealed that on or about 04/05/2026, (W1) requested resident-related information from the facility and stated concerns regarding incomplete information. Interviews conducted during the investigation, along with records reviewed, revealed ongoing communication and coordination between the facility and the resident representative. Interview with staff (S1) revealed that the facility received Power of Attorney documentation for resident (R1) in approximately early April 2026 and collaborated with the resident representative regarding resident medications, hospice-related information, physician coordination, and resident care needs. Interview with staff (S4) revealed that requests for records were referred to administration for review and processing. Review of facility records, internal notes, and text message communications revealed ongoing communication and coordination between the facility and (W1) regarding resident care, medical providers, medications, and resident preferences. Based on interviews conducted, and records reviewed made during the investigation, the Department did not find sufficient evidence to support that the facility intentionally refused to provide resident records or medical-related information to the authorized representative. Therefore, the allegation is unsubstantiated. Regarding the allegation, “Staff physically abused resident during care,” it was alleged that facility staff handled resident (R1) inappropriately during care assistance. Interviews conducted with residents (R2-R5) revealed that residents reported feeling safe in the facility and denied observing staff physically mistreat residents. Interview with resident (R1) revealed that (R1) denied staff handling resident (R1) inappropriately. During the interview, (R1) appeared emotional and had difficulty clearly recalling or explaining certain events and care concerns. Interviews conducted with staff (S1-S4) revealed that resident (R1) occasionally resisted care and redirection during shower assistance. Record review revealed resident (R1) had cognitive and medical conditions requiring supervision and assistance with activities of daily living. Review of MARs, daily care records, internal facility notes, and text message communications revealed ongoing staff assistance with resident care, showering, medication administration, and behavioral redirection. Based on interviews conducted, records reviewed, and observations made during the investigation, the Department did not find sufficient evidence to support the allegation that facility staff physically abused resident (R1). Therefore, the allegation is unsubstantiated. No deficiencies were cited at this time. No deficiencies were cited during today’s visit. An exit interview was conducted with the administrator.the state’s words, verbatim · CDSS document, May 6, 2026 · control 11-AS-20260427141713

Allegation investigated: Facility will not release resident records to authorized representative. Staff physically abused resident in care.

On 05/06/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted a complaint investigation visit at the facility and met with Administrator Shimon Bayar. The investigation consisted of the following: The Department interviewed four (4) staff members (S1-S4), interviewed five (5) residents (R1-R5), interviewed Witness (W1), conducted observations of the facility environment, and reviewed records including LIC 601, LIC 602, Admission Agreement, Durable Power of Attorney for Health Care, Medication Administration Records (MARs), daily care flow sheets, internal facility notes, and text message communications between the facility and resident representative. The investigation revealed the following: Regarding the allegation, “Facility will not release resident records to authorized representative,” it was alleged that the facility failed to provide requested resident-related information to (W1). Please see rerport continuation on (LIC9099-C) Unsubstantiated Interview with (W1) revealed that on or about 04/05/2026, (W1) requested resident-related information from the facility and stated concerns regarding incomplete information. Interviews conducted during the investigation, along with records reviewed, revealed ongoing communication and coordination between the facility and the resident representative. Interview with staff (S1) revealed that the facility received Power of Attorney documentation for resident (R1) in approximately early April 2026 and collaborated with the resident representative regarding resident medications, hospice-related information, physician coordination, and resident care needs. Interview with staff (S4) revealed that requests for records were referred to administration for review and processing. Review of facility records, internal notes, and text message communications revealed ongoing communication and coordination between the facility and (W1) regarding resident care, medical providers, medications, and resident preferences. Based on interviews conducted, and records reviewed made during the investigation, the Department did not find sufficient evidence to support that the facility intentionally refused to provide resident records or medical-related information to the authorized representative. Therefore, the allegation is unsubstantiated. Regarding the allegation, “Staff physically abused resident during care,” it was alleged that facility staff handled resident (R1) inappropriately during care assistance. Interviews conducted with residents (R2-R5) revealed that residents reported feeling safe in the facility and denied observing staff physically mistreat residents. Interview with resident (R1) revealed that (R1) denied staff handling resident (R1) inappropriately. During the interview, (R1) appeared emotional and had difficulty clearly recalling or explaining certain events and care concerns. Interviews conducted with staff (S1-S4) revealed that resident (R1) occasionally resisted care and redirection during shower assistance. Record review revealed resident (R1) had cognitive and medical conditions requiring supervision and assistance with activities of daily living. Review of MARs, daily care records, internal facility notes, and text message communications revealed ongoing staff assistance with resident care, showering, medication administration, and behavioral redirection. Based on interviews conducted, records reviewed, and observations made during the investigation, the Department did not find sufficient evidence to support the allegation that facility staff physically abused resident (R1). Therefore, the allegation is unsubstantiated. No deficiencies were cited at this time. No deficiencies were cited during today’s visit. An exit interview was conducted with the administrator.the state’s words, verbatim · CDSS document, May 6, 2026 · control 11-AS-20260427141713

Allegation investigated: Staff inappropriate handled resident in care. Staff sexually abused a resident. Facility staff physically abused resident.

On 03/23/2026 at 10:53am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent visit at this facility to deliver the complaint findings for the allegations above. During today’s visit, LPA met with Freddie Brown (caregiver) and explained the purpose of the visit. The investigation consisted of the following: On 01/30/2025 at 11:45am, the department, conducted interviews on 01/30/2026 between the hours of 12:35pm - 1:05pm with Administrator (A1), Staff (S1-S6) & Resident 2 (R2) - Resident (R4) and on 2/25/2026 at approximately 1530 hours with Resident 1 (R1) . The department requested copies of Resident Roster (dated 07/02/2025), Staff Roster (dated 07/24/2025), Serious Incident Reports (dated 1/18/2026 & 1/27/2026), Residents R1-R6: LIC 601 Emergency Identification Information (R1-no date, R2-dated 11/13/2025, R3-no date, R4-dated 05/22/2024, R5-no date, and R6-dated 06/23/2025); LIC 602 Physician Reports (R1-dated 04/04/2025, R2-dated 11/12/2025, R3-dated 02/13/2025, R4-dated 08/07/2025, R5-dated 01/27/2025, and R6-08/29/2025); and LIC 625 Appraisal Needs & Services (R1-dated 04/10/2025, R2-dated 11/14/2025, R3-dated 04/10/2025, R4-dated 05/22/2025, and R5-dated 05/01/2024). For the period of December 2025 through January 2026: Medication Administration Records, Blood Pressure & Glucose Level logs, Flow Charts of Daily Activities, and Resident Care Logs for Residents R1 - R6. Unsubstantiated The investigation revealed the following: Allegation: Staff handled resident in a rough manner It is alleged that staff handled a resident roughly during care, including squeezing the resident’s leg and being rough while assisting with dressing and footwear. On 01/30/2026, between the hours of 12:09pm - 12:30pm, the department interviewed the Administrator (A1) in regards to the allegation. A1 denied the allegation and stating no complaints of roughness had been made nor reported. The caregivers ensure to assist residents with comfort through communication and routine check-ins. On 01/30/2026, between the hours of 12:35pm - 1:05pm, the department interviewed 3 staff regarding the allegation. 1 of 3 staff were aware of the allegation and reported that a resident complained about staff being rough; however, staff attributed the complaint to the resident’s confusion and cognitive impairment. 2 of 3 denied the allegation and mentioned they assist residents respectfully, communicate during care, and have never been rough nor received complaints On 01/30/2026, between the hours of 12:55pm - 1:05pm & on 02/25//2026 at 1530 hours, the department interviewed 4 resident regarding the allegation. 4 of 4 residents denied the allegation & indicated staff treat them respectfully, communicate during care, and are not rough. Of the 4 residents who denied the allegation, 1 resident reported experiencing confusion at times but denied any mistreatment. On 03/20/2026, between the hours 12:30pm - 12:45pm, the department conducted a records review and observed no documentation was found supporting concerns related to staff handling residents in a rough manner. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation 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. Allegation: Staff sexually abused a resident It is alleged that a resident reported being physically abused by staff and stated that staff were beating the resident; it was also reported the resident had bruising on her body. On 01/30/2026, between the hours of 12:09pm - 12:30pm, the department interviewed the Administrator (A1) in regards to the allegation. A1 denied the allegation, stating no reports of sexual abuse had been received, nor have residents expressed discomfort with staff. A1 also mentioned no inappropriate conduct had been observed by the staff in regards to the residents. On 01/30/2026, between the hours of 12:35pm - 1:05pm, the department interviewed 3 staff regarding the allegation. 2 of 3 staff denied the allegation and indicated no resident has reported sexual abuse. All the staff mentioned not witnessing any inappropriate touching. 1 of 3 staff was aware of the allegation and reported that a resident made statements suggestive of sexual abuse.However, staff attributed the statements to one of the resident’s confusion and noted the resident prefers to complete tasks independently. On 01/30/2026, between the hours of 12:55pm - 1:05pm & on 02/25//2026 at 1530 hours, the department interviewed 4 resident regarding the allegation. 4 of 4 residents denied the allegation, stating no staff have touched them inappropriately, made them feel uncomfortable, nor made sexual advances. R1 did not disclose any sexual abuse by any of the caregivers in the facility and denied being harmed or abused by anyone in the facility. On 03/20/2026, between the hours 12:30pm - 12:45pm, the department conducted a records review and observed no documentation or reports were identified indicating sexual abuse involving staff or residents. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation 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. Allegation: Facility staff physically abused resident. It was alleged, a resident reported being physically abused by staff and stated that staff were beating the resident; it was also reported the resident had bruising on their body. On 01/30/2026, between the hours of 12:09pm - 12:30pm, the department interviewed the Administrator (A1) in regards to the allegation.A1 denied the allegation. A1 mentioned no resident reported any incidents of sexual abuse were observed. On 01/30/2026, between the hours of 12:35pm - 1:05pm, the department interviewed 3 staff regarding the allegation. 3 of 3 staff denied the allegation and mentioned not witnessing nor engaging in any physical abuse. Staff reported that any observed injuries are documented and may occur due to falls. On 01/30/2026, between the hours of 12:55pm - 1:05pm & on 02/25//2026 at 1530 hours, the department interviewed 4 resident regarding the allegation. 4 of 4 residents denied the allegation and stated no staff have physically harmed them. Also all 4 residents indicated not witnessing abuse nor unexplained injuries. R1 did not disclose any physical abuse by any of the caregivers in the facility and denied being harmed or abused by anyone in the facility. On 03/20/2026, between the hours 12:30pm - 12:45pm, the department conducted a records review and observed the following the LIC 624 Unusual Incident/Injury Report (dated 01/18/2026) stated R1 appeared more confused than usual on Saturday and R1 balance was unsteady. R1 lost their balance a couple of times and had to hold on to things for support. While walking in the living room R1 fell. R1 insisted they were okay and nothing hurt. Staff did not observe any bruising but the next day R1's ankle was swollen. R1 went to the emergency room which determined R1 had a fractured ankle which result in R1 being provided a boot to keep on R1's foot anytime R1 uses their foot. On 01/27/2026, another LIC 624 Unusual Incident/Injury Report mentioned R1 wandered in the living room in the middle of the night. Staff went to check on R1 upon hearing noise. R1 fell and bumped their head. Staff called 911 which came to the facility and examined R1 upon going to the hospital with R1's family being informed. Ultimately, the department observed no documentation to support the allegation. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation 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.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 11-AS-20260127100239

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced annual required 1-year visit with the primary focus on infection control measures and the use of the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms, and LPA's temperature was checked. LPA Bunker met with staff members Freddie Brown and Putri Rahayu and explained the purpose of today's annual inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently six (6) residents in placement. LPA Bunker and staff member Freddie Brown toured the facility, which is is a single-story family home located in a residential neighborhood. The home consists of a living room, dining area, kitchen, seven (7) bedrooms, three (3) bathrooms, a laundry room, a detached garage, and an indoor/outdoor activity area. The outdoor space features a shaded area with patio furniture, including tables and chairs. Bedrooms #1 to #6 are designated as the residents' rooms, while bedroom #7 is assigned for the live-in staff. Due to time constraints, LPA was unable to complete the full inspection and will return at a later date to finalize the visit. No deficiencies were cited during this visit. An exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 17, 2025

Allegation investigated: Staff did not ensure resident's dietary needs were met. Staff threatened resident. Staff restricted resident's visitor(s).

On 08/20/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Eilat Nahum, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA inspected the facility, interviewed Staff S1-S4, interviewed Residents R1-R6, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Admission Agreement, Addendum - Resident Rights, Physician’s Report, Physician’s Orders, Needs and Service Plan, Identification and Emergency Information, Personal Rights Residential Care Facility for the Elderly, and Visitor Sign-In Logs from 04/01/2025 through 8/20/2025. The investigation revealed the following: Unsubstantiated Allegation: Staff did not ensure resident’s dietary needs were met The allegation alleges the facility is serving a resident meat despite knowing they are a vegetarian and admitted knowingly serving them meat. During the facility inspection, LPA observed food that is appropriate for residents with a vegetarian diet. Additionally, LPA observed vegetarian meals available for residents. During record review, LPA received and reviewed Resident R1’s Identification and Emergency Information that states in the Comments R1 is a vegetarian. During review of R1's Physician’s Report dated 04/04/2025 indicates that R1 does not have a special diet. In the Addendum - Personal Rights of the admission packet under Resident Rights, number 7 states residents have the right “To be served food of the quality and in the quantity necessary to meet their nutritional needs.” During interviews with Staff S1-S4, were asked if residents with special diets and preferred diets are accommodated, four (4) out of four (4) stated resident’s special diets and preferred diets are followed. Additionally, during an interview with S1 and S2 stated if a resident does not want what is being served, they will make them something they want to eat. During interviews with Residents R1-R6, were asked if their special diet and/or preferred diets are followed, four (4) out of six (6) stated their special diet and preferred diets are followed. Two (2) out of six (6) stated they do not have a special or preferred diet. Additionally, six (6) out of six (6) residents stated the staff will make them whatever they want to eat if they don’t want what is being served. During an interview with R1, stated staff will ask if they want want is being served, the staff informs them there is meat in the item, and that staff will pick out the meat and they pick out any additional pieces they see. Allegation: Staff threatened resident. The allegation alleges the facility staff threatened to withhold their medication if they did not finish their food. During the facility inspection, LPA observed Resident Rights posted in the facility. During record review, LPA received and reviewed Addendum of the admission packet under Resident Rights number 8 states the resident has the right "To make choices concerning their daily life in the facility." and number 10. that states the resident has the right "To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse." LPA received and reviewed R1's Personal Rights Residential Care Facilities For the Elderly (LIC613C) dated 04/09/2025 that states in number "(3) To be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature, such as withholding of monetary allowances or interfering with daily living functions such as eating or sleeping patterns or elimination." During interviews with Staff S1-S4, were asked if they have or have seen or heard staff threaten a resident to eat something they did not want to, four (4) out of four (4) stated they have not threatened a resident nor have they heard another staff threaten a resident. Additionally, during an interview with Staff S1 and S2, stated they have never threatened a resident to eat their food, but they encourage Resident R1 to eat their food before taking their medication due to the medication needing to be taken with food. During interviews with Residents R1-R6, were asked if staff have threatened to withheld their medication due to not consuming all their food, six (6) out of six (6) stated no, staff have not threatened to withhold their medication due to not eating all their food. Allegation: Staff restricted resident’s visitor(s) The allegation alleges the facility staff restricted a visitor from visiting with a resident for about two (2) months. During the facility inspection, LPA observed the Rights of Residents posted in the facility. LPA reviewed the visitor sign-in logs at the entrance and observed Resident R1 has had multiple visits while residing in the facility. During record review, LPA received and reviewed the Admission Agreement for Resident R1, dated 04/09/2025, that states on page 5 “Visiting hours are from 10AM to 5PM.” In the Addendum of the Admission Agreement lists Resident Right that states in number 24. the resident has the right “To consent to have relatives and other individuals of the resident's choosing visit during reasonable hours, privately and without prior notice. Additionally, in the admission packet, is the Personal Rights Residential Care Facilities For the Elderly (LIC613C) dated 04/09/2025, states in number (11) To have his/her visitor, including ombudspersons and advocacy representatives permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. During interviews with Staff S1-S4, were asked if they have restricted a resident’s visitations with friends and family, four (4) out of four (4) stated they have not limited a resident’s visitations with friends or family. Additionally, during an interview with S1 stated they were asked by a resident’s family to deny visitation of a resident’s friend and they informed the family they may not restrict a residents visitation rights. During interviews with Residents R1-R6, were asked if the staff have restricted their visitations with friends and family at any time, six (6) out of six (6) stated staff have not restricted their visitation. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Caregiver, Freddie Brown, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 11-AS-20250812085514

Allegation investigated: Staff are refusing to take the resident back into care.

On 6/19/25, at 09:00am, the department conducted an initial complaint visit to the facility and was greeted by Eilat Nahum, Director, and Freddie Brown, Caregiver. Later joined by phone was Shimon Bayer, Administrator. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff, and deliver findings for the allegation mentioned above. The investigation consisted of the following: The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S3), and witness (W1) from 9:00am-11:00am. The department received the following documents: Resident Roster (Dated: 04/09/2025), Staff Roster (Dated: 05/2025), Admission Agreement (Dated: 05/01/2025), ID Emergency Information (Dated: 5/1/2025), Physicians Report (Dated: 04/14/2025), Resident Appraisal Information (Dated:04/22/2025), Appraisal/Needs And Service Plan (Dated: 05/05/2025), Unusual Incident/Injury Reports (Dated: 5/11/25,5/19/25, 5/20/25, 5/23/25, 5/30/25, 6/4/25, 6/8/25, 6/9/25), Facility Resident Notes (Dated: 05/07/2025-06/13/2025)...... Report Continued On LIC9099-C Unsubstantiated Olive View Medical Center Records (Dated: 05/24/2025), Kaiser After Visit Summary (Dated: 6/6/25, 6/8/25), and Text Message Thread (Dated: 06/12/2025 & 06/13/2025) were received from the facility. The investigation revealed the following: Allegation- Staff are refusing to take the resident back into care. The details of the complaint alleged that the facility did not take resident (R1) back after they were hospitalized. It was reported that the resident was discharged on 06/12/25 but the facility stated the resident could not come back into the facility because they needed a higher level of care. On 6/19/25, from 9:00am-11:00am, the department interviewed staff (S1-S3) and witness (W1). All staff denied the allegation that Staff are refusing to take the resident back into care. Staff stated that they did not refuse to take the resident back. They stated that they talked to the family member and said that the resident (R1) needed a higher level of care and would require a 1 on 1 caregiver. They state that the condition of the resident had changed and become combative towards staff, residents, and they feared that R1 would injure themselves. Staff also stated that they told the family member of R1 on 6/12/25, that prior to the resident returning they would need to do a reappraisal of the resident in the hospital. Staff stated that the family member texted them on 6/12/25, stating that R1 won’t have to return to the facility, and that they would be picking up R1s personal belongings the next day. Additionally, they state that the family member wanted them to prepare any final paperwork and issue a refund for 6/14-6/30/2025. Staff stated that they were not given an opportunity to do a reappraisal of the resident and take any further action, given what they would have discovered in the reappraisal. They state the resident was able to come back but a reappraisal needed to be completed first. The department also interviewed witness (W1), and they stated that they received a phone call from an interested party stating that the facility would not allow the resident to come back unless they had a caregiver that could work 1 on 1 with the resident. They also stated that the resident was supposed to be discharged from Kaiser on 6/12/25 but had it pushed back until 6/13/25 to allow enough time to find another facility. W1 stated that luckily, the resident was admitted to a new facility on 6/13/25. The department reviewed the Resident Appraisal Information (Dated:04/22/2025), Appraisal/Needs And Service Plan (Dated: 05/05/2025), Unusual Incident/Injury Reports (Dated: 5/11/25,5/19/25, 5/20/25, 5/23/25, 5/30/25, 6/4/25, 6/8/25, 6/9/25), Facility Resident Notes (Dated: 05/07/2025-06/13/2025), Olive View Medical Center Records (Dated: 05/24/2025), Kaiser After Visit Summary (Dated: 6/6/25, 6/8/25), and Text Message Thread (Dated: 06/12/2025 & 06/13/2025) .The department observed from reviewing all documentation that the resident was suffering from a major neurocognitive disorder due to Alzheimer’s dementia disease. The department observed that when the resident was admitted, R1 was mild mannered and compliant. Report Continued On LIC9099-C Subsequently, the department observed that the residents’ behavior changed, according to documents and facility resident notes reviewed. The department reviewed incident reports that document the resident’s change in behavior such as slapping staff members, trying to climb out of their bedroom window, entering other residents’ room and disturbing them, and restricting staffs’ movement in the facility by preventing them from going into other parts of the facility to care for the other residents, by forcibly keeping a door closed, causing staff to call 911 for assistance. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff are refusing to take the resident back into care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur because of neglect, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted with Freddie Brown, Caregiver, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 11-AS-20250612122120

Allegation investigated: Staff does not provide adequate supervision resulting in resident falling on multiple occassions. Staff did not meet resident's care needs resulting in UTI.

On 06/19/25, Licensing Program Analysts (LPA), Antonine Richard, conducted an unannounced complaint visit to the facility listed above. LPA met with Designee Administrator Eilat Nahum and conducted an interview over the phone with Administrator Shimmy Bayar. The purpose of today’s visit was explained. During today’s visit, LPA conducted a facility inspection and interviewed Residents R2-R6, as well as Staff S1-S3. The following documents were reviewed and obtained: Staff Roster, Resident Roster, and documents for R1, including the Physician Report dated 04/14/25, the Admission Agreement dated 05/03/25, the Resident Appraisal dated 04/02/25, and Unusual Incident Reports dated 05/11/25, 05/19/25, 05/20/25, 05/23/25, 05/30/25, and 06/09/25. Facility notes dated 05/07/25 through 06/10/25, along with 40 hours of staff training in Behavior Management Training, Fall Prevention, and Safety Protocols dated 03/11/25, and 40 hours of training in Activities of Daily Living (ADLs) support dated 02/11/25, were also reviewed. Additionally, Hospital Discharge documents dated 05/24/25 and from 06/06/25 to 06/07/25 were obtained. Furthermore, documents pertinent to the investigation were reviewed and acquired. Unsubstantiated Allegation #1: Staff does not provide adequate supervision, resulting in residents falling on Multiple occasions. The complaint alleges that the staff did not provide adequate supervision for the resident, which resulted in the resident falling three times and requiring hospitalization. On June 19, 2025, between 9:30 AM and 11:00 AM, the LPA interviewed Administrator #1 (A1), who denied the allegations. A1 stated that they ensured all residents received adequate supervision and provided the necessary training to facility staff to care for the residents effectively. During the same time frame, the LPA interviewed three staff members (S1, S2, S3). All three staff members denied the allegations and asserted that they consistently provided supervised care for Resident #1 (R1) daily. Later, on June 19, 2025, between 11:30 AM and 12:30 PM, the LPA interviewed five residents (R2, R3, R4, R5, R6). All five residents denied the allegations and stated that the staff took good care of them. Records reviewed from R1’s medical discharge papers from Olive View Medical Center indicated that R1 fell on May 24, June 6, and June 7, 2025, but sustained no injuries. On June 19, 2025, records reviewed indicated that staff completed 40 hours of training in Fall Prevention and Safety Protocols, as well as in the use of medical equipment, including walkers, wheelchairs, and other devices that assist residents in their daily activities. The LPA observed one resident walking with a walker, assisted by staff, and another resident in a wheelchair, with staff present and ready to assist. The LPA also reviewed R1's Appraisal/Needs and Services Plan, which did not indicate that R1 was considered a fall risk. And does not need assistance walking. LPA could not interview resident R1 because R1 is no longer living at the facility. Based on the LPA observations, interviews, and record reviews, the preponderance of evidence has not been met. Although the allegation may have happened or is valid, there is insufficient evidence to prove whether the alleged violation did or did not take place; therefore, the allegation is unsubstantiated. Allegation #2: Staff did not meet the resident’s care needs, resulting in UTI. The complaint alleges that the facility is failing to provide proper care for Resident #1 (R1), leading to a urinary tract infection (UTI). R1 had to be hospitalized due to an accidental fall. On June 19, 2025, between 9:30 AM and 11:00 AM, the Licensing Program Analyst (LPA) interviewed Administrator #1 (A1), who denied the allegations. A1 stated that all residents receive 40 hours of training in Activities of Daily Living (ADL) Support, as well as Best Practices for Hygiene and Personal Care. During the same time frame, the LPA also interviewed three staff members (S1-S3). All three staff members denied the allegations and stated that they continuously assist R1 with hygiene and personal care. They also stated that they regularly change the resident R1 diapers. Later, on June 19, 2025, between 11:30 AM and 12:30 PM, the LPA interviewed five residents (R2-R6). All five residents denied the allegations, asserting that the staff provides them with good care. A review of the Preplacement and Service Plan indicated that R1 does not require assistance with meal consumption and walking. Additionally, interviews with three staff members revealed that they encourage residents to stay hydrated and provide water. Record reviews showed that staff received in-service training on infection control and prevention on March 7, 2025. Furthermore, five resident interviews confirmed that staff ensure residents drink plenty of water. LPA also interviewed with three residents who reported that staff change their diapers every two hours and as needed. The LPA observed water stations in the kitchen, living room, dining room, and bottled water available in residents' rooms. LPA could not interview resident R1 because R1 is no longer living at the facility. Regarding the allegation that staff did not meet the resident's care needs, resulting in a UTI, the Department found no evidence to support the claim. Based on record reviews, interviews, and observations. Although the allegations may have happened or is valid, there is not enough evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. Exit interview conducted. A copy of this report was provided to the staff Freddie Brown.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 11-AS-20250610105940

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Eilat Nahum , Administrator and Aviel Nahum and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents and an approved hospice waiver for 3 resident and 1 bedridden. Currently there are 6 residents in placement of which 2 are on hospice and 1 receiving home health services. The facility does not handle any of the residents’ money. This home is a single story home consisting of: (5) resident bedrooms, (3) Full bathroom, living room, kitchen ,dining area, laundry room an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 110.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. During todays visit LPA did not observe any deficiencies. Exit interview conducted with Aviel Nahumthe state’s words, verbatim · CDSS document, Nov 12, 2024