Mini Manor Home

Type of visit: Required - 1 Year

On 01/06/2023 at 1:30 pm, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, a risk assessment was conducted by LPA Alvizar via telephone with Staff, Eilat Nahum and the purpose of today’s visit was explained. Based on the assessment, the facility is clear of Covid-19 infection. The facility is licensed for six (6) non-ambulatory residents, of which one (1) can be bedridden. Facility is approved for three (3) hospice. Currently, there are five (5) residents present during today’s visit. LPA met with Caregiver, Lannie Nio and later Administrator, Eilat Nahum met us and toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station near the facility front entrance. All staff and residents were observed with a face covering. LPA observed required postings throughout the facility. All rooms were inspected. All rooms are shared. Bed linen were sufficient in amount, but mattresses needed bed covers, adequate lighting was provided, storage for resident personal belongings was observed. Furniture in the living room observed to be in good condition. There are no security bars or weapons on the premises. The client bathroom was checked, toilets and water faucets worked properly. The water temperature measured at 119.1 F. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Centrally stored medications were observed stored in their originally received containers and observed locked and inaccessible to residents in care. One fire extinguisher was observed towards front entrance. Cont on 9099C Outside grounds were toured, no bodies of water observed. Walkways around the home were clear of hazards. Common areas were observed with no cluttered; front doorway was free of obstruction. LPA observed the facility have an Administrator Certificate with valid date posted on the wall. Administrator, Eilat provided LPA a copy of Certificate of Liability Insurance. 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, Eilat Nahum.the state’s words, verbatim · CDSS document, Jan 6, 2023

Type of visit: Case Management - Health Checks

On 04/01/2022 Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Ulysess Coronel conducted a Case Management - Health and Safety Check to the above and met with Eilat Nahum Administrator. During today visit LPA and LPM conducted a tour of the facility and interviewed R2 and R3 who were former residents of Beit Shalom #197608630. No deficiencies were cited. A copy of this report was provided to Eilat Nahum, Licensee.the state’s words, verbatim · CDSS document, Apr 1, 2022

Type of visit: Required - 1 Year

On 01/27/2022 at 9:51 am, Licensing Program Analyst (LPA) Troy Agard and Licensing Program Manager (LPM) Angela Kendrick conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, a risk assessment was conducted by LPM Janae Hammond via telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for six (6) non-ambulatory residents, of which one (1) can be bedridden. Facility is approved for three (3) hospice. Currently, there are five (5) residents present during today’s visit. LPA met with Caregiver, Lanny Ttie and both toured the inside and outside grounds of the facility. LPA and LPM were properly screened for Covid-19 symptoms and temperature was checked. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station near the facility front entrance. All staff was observed with a face covering. LPA observed required postings throughout the facility. All rooms were inspected. All rooms are shared. Bed linen were sufficient in amount, but mattresses needed bed covers, adequate lighting was provided, storage for resident personal belongings was observed. Furniture in the living room observed to be in good condition. There are no security bars or weapons on the premises. The client bathroom was checked, toilets and water faucets worked properly. The water temperature measured at 119 F. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Cleaning supplies were observed unlocked. Centrally stored medications were observed stored in their originally received containers and observed locked and inaccessible to residents in care. One fire extinguisher was observed towards front entrance. Cont on 9099C Outside grounds were toured, no bodies of water observed. Walkways around the home were not clear of hazards. Common areas were observed cluttered; front doorway was free of obstruction. During a review of records, LPA observed the facility does not have an Administrator with a valid certification which is not in compliance with PIN 21-24CCLD. The following deficiencies were cited: 1) Personnel Records 87412 2) Resident Records 87506 3) Administrator - Qualifications and Duties 87405 4) Admission Agreements 87507 5) Personal Rights 87468.1 6) Maintenance and Operations 87303 7) Personnel Requirements – General 87411 Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapters 1 and 6, see LIC 809D An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2022

Allegation investigated: Staff hits residents while in care. Staff yells at residents while in care.

On 11/22/21 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit, to Mini Manor Facility, regarding allegations above. LPA Spoke with Licensee Eliat Naham, and was met by staff Petrus Rawung, the purpose of the visit was explained. The investigation consisted of the following: Physical Plant tour, Resident Interviews, Staff interviews, Record Review of requested documents (Staff Roster, Resident Roster, Admissions Agreements). Regarding Allegation: Staff hits residents while in care. Interviews conducted with Residents in care (R1-R4), revealed that they have not been physically hit by staff, nor have they witnessed any other residents being hit. LPA did not observe any resident to have bruising. All residents generally stated that staff treat them with respect. Based on Observation, Interviews and Record Review the LPA finds that Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiated Regarding Allegation: Staff yells at residents while in care. Interviews conducted with Residents in Care (R1-R3) revealed that staff generally treat residents with respect, and do not yell or raise their voice towards residents. R1-R4 generally stated they have not witnessed staff yelling at other residents. Staff interview stated that they do not yell at residents. LPA did not observe any staff yell at residents while conducting interviews. Therefore; Based on LPA observation, and interviews conducted the LPA finds that although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An Exit interview was conducted and a copy of this report was provided. No citations issued during this visit.the state’s words, verbatim · CDSS document, Nov 22, 2021 · control 11-AS-20211117160729

Allegation investigated: Staff unable to communicate residents needs due to language barrier.

On 11/8/21 Licensing Program Analysts (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with… and explained the purpose of today’s visit. The investigation consisted of the following: On 9/10/21, Licensing Program Analysts (LPA) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond initiated a complaint investigation regarding the above allegations. LPA conducted interviews with Staff #1-2 and residents #2-4. LPA requested the following documents: Personnel report (LIC 500) and Client Roster, staff # 1-2 training records and residents #1-3 Admissions Agreement, Physicians reports, needs and service. The investigation revealed the following: Regarding allegation: Staff unable to communicate residents needs due to language barrier. LIC 9099-C is on the next page Substantiated On 9/10/21, LPA interviewed S1 regarding the above allegation and had to difficulty during the interview process. LPA had to keep rephrasing question in order for S1 to understand the question. LPA attempted to interview S2, asked staff if a resident had a medical emergency what was the protocol? Staff could not answer and S1 was telling staff what to say. Interviewed residents #2-6 and they stated had difficulties communication with staff #1-2. On 10/1/21 LPA interviewed the administrator, she stated, stated staff members do not have a problem communicating. LPA asked does residents have to rephrase question when they need assistance? She stated they do and S2 doesn’t speak English but S1 would translate. She stated resident #1 spoke only Spanish but they would call someone to translate. On 10/4/21 conducted interview with RP was stated R1 is not mobile and would crawl out of bed and caregivers would help resident back. RP stated there was a language barrier between staff and R1. Based on information obtained there is sufficient evidence to support the above allegation. Based on LPA observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 being cited on the attached LIC 9099D. Exit Interview Conducted, appeal rights were explained and a copy of this report was provided to Nahum .the state’s words, verbatim · CDSS document, Nov 8, 2021 · control 11-AS-20210903123002

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Nov 15, 2021

87411 (d) (3) Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge … (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability .. This requirement was not met as evidence by: Based on observation and interviews conducted, staff cannot communicate with residents. On 9/10/21 LPA had a hard time communicating with staff #1 and Staff #2 could not speak English. This a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: Licensee shall ensure all staffs are able to communicate with residents and visitors to meet resident’s need and able to communicate and understand at all time. Licensee will submit written statement as to how staff #1 and 2 will understand and communicate in order to meet the residents in needs by POC due date 11/15/21.

Allegation investigated: Staff not maintaining resident’s hygiene. Food service not provided to resident.

Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with Nahum and explained the purpose of today’s visit. The investigation consisted of following: Interviews and records review. On 9/10/21, LPA and LPM conducted a Health & Safety check. LPA conducted interviews with Staff #1-2 and residents #1-3. LPA was unable to interview resident #4 due to not being home and resident #5, no longer lives at the facility. LPA requested the following documents: staff #1-2 training records and residents #1-3 physicians reports and emergency contacts. Investigation revealed the following: Staff not maintaining resident’s hygiene. LIC9099-C Unsubstantiated On 9/10/21, LPA interviewed Staff #1 (S1) regarding the above allegation. S1 stated residents are assisted with bathing and if needed changing of clothes. Staff stated resident clothes were washed. LPA attempted to interview staff #2 but staff did not speak English. LPA was not able to interview resident #1, due to no longer living at the facility. LPA interviewed residents # 2-4, all residents stated they have no problem with staff assisting them. On 9/27 and 10/4/21, LPA interviewed the reporting parties, they both stated had seen resident #1 clothes was not clean and nails were dirty. On 10/1/21, LPA asked administrator how often does the staff clean the resident’s clothes? She stated clothes are cleaned every day. She also stated residents that need assistance with showering are bathed in the AM. Regarding allegation: Food service not provided to resident. On 9/10/21, LPA spoke interview staff #1 regarding the above allegation. S1 stated residents are provided 3 meals a day and sometimes snack. LPA attempted to interview staff #2 but staff did not speak English. LPA interview residents # 2-6, all residents stated they receive three meals a day and sometimes snacks. On 10/1/21, LPA asked administrator, how often are residents provide food? She stated residents are provided three meals a day. LPA asked was there concern of some residents not eating? She stated there was no concern and if there were caregivers are trained to notify her. LPA interviewed R1’s relative informed resident may not had wanted to eat due to medical condition. On 10/4/21, LPA interview the Reporting Party (RP), RP stated R1 informed staff was not providing food. RP stated had spoken to S1 and informed R1 was refusing to eat and told the administrator. LPA reviewed R1’s records and health conditions may have prevented resident from eating. Based on LPA’s interviews conducted and records review during the investigation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and report was given to Nahum.the state’s words, verbatim · CDSS document, Nov 8, 2021 · control 11-AS-20210903123002

Allegation investigated: Facility staff did not take visitor's temperature.

On 9/30/21, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint investigation for the above listed allegation. LPA met with Eilat Nahum, the facility Administrator and the purpose of the visit was explained. LPA Brown requested and obtained copies of staff and client roster. LPA conducted an interview with the administrator. LPA reviewed residents #1-4 records. During today’s visit, LPA toured the physical plant. LPA conducted interviews with staff #1 and residents #1-4. LPA was not able to interview was unable to interview staff #2 due to level of communication. The investigation revealed the following: Interviews, records review and observations. Regarding allegation: Facility staff did not take visitor's temperature. LIC 9099-C is on the next page. Substantiated On 9/30/21, LPA interview Administrator Nahum regarding the above allegation. Nahum stated staff is supposed to check all visitor’s temperature, screen and enter into visitor's log book. Administrator stated staff is trained every couple of months on protocol. LPA conducted an interview with Staff #1, staff stated they check resident’s temperature every day. LPA attempted to interview staff #2 but could not answer any of LPA's questions. Staff #1 was trying to intervene and translate when LPA was speaking to staff #2. LPA interview residents #1-4 and 3 out of 4 residents stated they do not get their temperatures check. Residents #1-3 stated they only get their blood pressures check. LPA interview reporting party and stated was at the facility a couple times and temperature was not taking and wasn’t screen. RP stated Staff #1 doesn’t wear a mask all the time. During today's visit Staff #1 did not screen LPA's temperature or screen. LPA explained to staff #1 and administrator that temperatures of all visitors will need to be taken at the point of entry. Staff #1 later took LPAs temperature and recorded in log bood. LPA reviewed residents #1-4 records and temperatures was not recorded for 9/26/21-9/30/21. LPA did not observe temperature log for staff #1-2. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit Interview Conducted, appeal rights were explained, and a copy of this report was furnished.the state’s words, verbatim · CDSS document, Sep 30, 2021 · control 11-AS-20210923094710

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: Oct 8, 2021

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on LPAs interviews and document reviews Staff #1 did not take temperature at entry. Residents #1-4 and staff #1-2 temperatures were not log. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will have an in service training with all staff on Title 22 regulation section for residents to be provided safe and healthful accommodations. Administrator will provide a statement that she trained staff on temperature checking/screening and documentation by POC due date 10/8/21.

Type of visit: Case Management - Incident

On 9/30/21, Licensing Program Analysts (LPA) Martessa Brown conducted a case management. LPA was met by Lan Nio, the Caregiver. LPA explained the purpose of todays visit. LPA was told by administrator the police came to facility yesterday regarding resident R1 and staff #1. LPA did not receive an incident or a police report. Administrator stated was in the process the reports. Staff #1, showed LPA a written statement that was in a note book related to the incident. During today's visit LPA observed injures to resident #1. LPA interviewed r1 regarding the incident. LPA asked administrator regarding this incident and informed her LPA did not receive an incident report. Deficiency Cited Under California Code of Regulations Title 22, Division 6 Chapter 8 and civil penalties assessed. See attached LIC 809-D An exit interview conducted report and appeal rights given .the state’s words, verbatim · CDSS document, Sep 30, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(D) · Plan of correction due date: Oct 8, 2021

87211 Reporting Requirement: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse... This requirement was not met as evidence by: During LPA's interviews conducted with administrator and resident #1. Administrator did not submit an incident report to LPA regarding R1's incident's at the facility. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will provide incident reports and submit to LPA. Administrator will review Title 22 and provide a written statement that she read and understood the regulation and will submit to LPA by POC due date 10/8/21.

Allegation investigated: Staff engaged in a verbal altercation with resident. Staff not treating resident with dignity. Resident engaged in an altercation towards resident. Staff takes residents belongings.

Licensing Program Analysts (LPAs) Martessa Brown and Ulysses Coronel conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with Eilat Nahum and explained the purpose of today’s visit. The investigation consisted of following: Interviews and records review. On 8/19/21 LPA conducted a 10-day health & safety check visit. LPA toured the facility with house manager and requested the following documents: Resident #1 admission agreement, physician report, needs & service, emergency contact and Staff #1-2 training. The investigation revealed the following: Staff engaged in a verbal altercation with resident. On 8/18/21, LPA spoke to Resident (R1). R1 stated words were exchange in the kitchen and Staff (S1) spit in R1’s face. R1 stated was upset threw the food on the floor. LIC9099-C is on the next page. Unsubstantiated On 9/10/21 LPA interviewed Residents #2-4 and they stated did not see an altercation between resident staff. On 9/20/21, LPA interviewed House Manage (HM) stated there was an altercation between R1 and S1. She stated S1 is always angry and was upset and knocked down the food. She stated did not know what happened. LPA was not able to interview R5 was not present. Staff not treating resident with dignity. On 8/18/21, LPA spoke to Resident (R1). R1 stated Staff (S1) is always cursing when communicating. R1stated S1 is always upset and administrator does nothing about it. On 9/10/21 LPA interviewed residents R#2-3 stated staff has not yelled at them. R4 stated staff S1 has yelled at them. Resident engaged in an altercation towards resident. On 8/18/21, LPA spoke to Resident (R1). R1 stated a former resident hit him multiple times while on the disable ramp. Resident charge at R1 with a shovel at was hit. R1 stated called 911 due to S1 not calling. R1 stated reported to administrator and she did nothing. On 9/10/21 LPA interviewed Residents #2-4 and they stated have not had altercations with residents and did not see an incident between R1 and the other resident. On 9/20/21, LPA interviewed House Manage (HM) stated there was no altercation between residents. Staff takes residents belongings On 8/18/21, LPA spoke to Resident (R1). R1 stated administrator came into the room without permission and took a teapot. On 9/10/21 LPA interviewed Residents #2-4 and they stated staff has not taken their belongings. LPA interviewed House Manage (HM) stated they go into residents’ room once to make sure rooms are clean. She stated they will take residents belongings if they have sharp items. Based on LPAs interviews conducted and records review during the investigation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and report provided.the state’s words, verbatim · CDSS document, Sep 23, 2021 · control 11-AS-20210812133820

Allegation investigated: Resident not awarded privacy

Licensing Program Analysts (LPAs) Martessa Brown and Ulysses Coronel conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with Eliat Nahum, the administrator and explained the purpose of today’s visit. The investigation consisted of following: Interviews and records review. On 9/10/21, LPA & LPM conducted a 10-day visit and toured physical plant. LPA interviewed Staff #1, residents #1-4. LPA attempted to interview staff #2 but unable to communicate. LPA did not interview resident #5 wasn’t present..LPA requested the following documents: staff #1-2 records and residents #1-3 files. On 9/23/21 LPA conducted R1’s record review. The investigation revealed the following: Resident not awarded privacy On 9/7, LPA interview Reporting Parting (RP) regarding the above allegation. RP stated while R1 was changing in the bathroom and the door was closed, that 2 men open the door. LIC 9099 on the next pages. Unsubstantiated RP stated R1 had door on multiple occasions. On 9/10, LPA needed a Spanish Translator LPA Ana Soto for Resident R1. R1 disclosed to LPA Soto, while in the restroom. Staff S1 and S2 kept knocking and pushed the door open while other residents were there and laughing. On 9/10/21, LPA conducted interview with S1, stated R1 had took a long time in the restroom. R1 was not opening the door and had to check on the resident. LPA attempted to interview S2 but could not communicate. On 9/20/21, LPA interviewed House Manger HM, stated no one has barged in on R1. She stated R1 would stay in the restroom for a long-time washing clothes, while others needed to use the restroom. HM stated S1 told her about most recent restroom incident. She stated S1 informed her R1 was taking a long time in the restroom and became nervous and open the door with a key. On 9/10/21, LPA interview residents #2-4, they stated could her a lot of yelling by the restroom but could not actual see what was happening. LPA was not able to interview R5 due to not being there. Resident #2 stated the door was open on R1 and would here yelling. R1's records reviewed that resident had a mental condition that may reflect her responses to the allegation. Based on LPA's interviews conducted and records review during the investigation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and report was provided. Facility staff speak to resident in an aggressive manner. On 9/7/21, LPA interview Reporting Parting (RP) regarding the above allegation. RP stated S1 yells at her. R1 stated on 9/1/21, S1 talked to her in aggressively. On 9/10/21, LPA spoke to R2 and resident stated S1 yells all the time at residents. LPA spoke to R3-R4, stated S1 has not yelled at them but has heard S1 yell at other residents. LPA did not interview R#5 was not present. On 9/10/21, LPA interviewed S1 and staff stated doesn’t yell at resident. LPA attempted to interview S2 but doesn’t speak English. On 9/20/21, LPA spoke to house manager and she stated has not heard staff yell at residents. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit Interview Conducted, appeal rights were explained and a copy of this report was furnished.the state’s words, verbatim · CDSS document, Sep 23, 2021 · control 11-AS-20210902113641

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Sep 30, 2021

87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions.. This requirement was not met as evidence by: Based on LPAs interviews, R1 stated S1 yells all the time. Residents stated they have heard S1 yelling a them and other residents. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2021

Plan of correction: Administrator will have an in service training with all staff on Title 22 regulation section, all residents personal rights are protected. To be free from punishment, humiliation and intimidation. Administrator will provide to LPA by POC due date 9/30/21.

Type of visit: Case Management - Deficiencies

On 9/10/21 Licensing Program Analysts (LPA) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond conducted a case management. LPA and LPM was met by Naome Leibov, the house manager. LPA explained the purpose of today’s visit. During today’s visit LPA and LPM observed Caregivers (CG) #1-2 and it was determine that CG #2 was not associated to the facility. CG #1 was not fingerprint cleared. LPA called the El Segundo office to confirm caregivers was not finger print cleared and associated to the facility, During today’s visit LPA observed assistant administrator Eilat Nahum conducted a search in resident #1's bedroom without a reasonable basis. Administrator confiscated R1's baseball bat. During today’s visit LPA observed residents #2's bedroom was having other resident's going in and out being used as a passageway in order to exit into the backyard. During today’s visit LPA observed facility staff uses resident #2's room to store incontinent supplies in a cabinet .Due time constraint LPA may issue additional deficiencies at a later date. Deficiencies Cited Under California Code of Regulations Title 22, Division 6 Chapter 8 and civil penalties assessed. Exit interview conducted report and appeal rights was given to Naome Leibov, the House Manager.the state’s words, verbatim · CDSS document, Sep 10, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1)(2) · Plan of correction due date: Sep 10, 2021

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17...(1) Obtain a California clearance or a criminal record exemption as required by the Department.. (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidence by: LPA and LPM observed Caregivers #1-2 both workiing in the facility. CG #1 Djie Nio did not have finger print clearance and CG #2 Petrus Canssisus was not associated. LPA and LPM called the El Segundo office and confirmed. LPA/LPM also confirmed. This poses and immediate health and safety risk to all residence at the facility.the state’s words, verbatim · CDSS document, Sep 10, 2021

Plan of correction: Administrator will submit proof that Caregivers #1 Djie Nio finger print cleared and caregivers #2 Petrus Canssisus was not associated to the facility. All documents must be submitted to LPA by poc date 9/11/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Sep 16, 2021

Personal rights of residents in all facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: LPA/LPM observed during visit Administrator conducting a search in residents #1 room with no reasonable basis and confiscated a bat. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2021

Plan of correction: Administrator to conduct a training in personal rights for all residents and submit training documents to LPA by poc dates including sign in sheets bu POC Date 9/16/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 16, 2021

Personal rights of residents in all facilities: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: LPA/LPM observed incontinent supplies being stored in residents #2's bedroom in a cabinet. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2021

Plan of correction: Administrator should room incontinent supplies from resident #2's bedroom to afford resident #2 privacy. Administrator will submit to LPA proof of by poc 9/16/21