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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608859
Report Date: 04/06/2021
Date Signed: 04/08/2021 04:49:33 PM

Document Has Been Signed on 04/08/2021 04:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EILAT'S MANORFACILITY NUMBER:
197608859
ADMINISTRATOR:MIRIAM RUDESFACILITY TYPE:
740
ADDRESS:1621 S. SHERBOURNE DRIVETELEPHONE:
(310) 273-3133
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 5DATE:
04/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Miriam RudesTIME COMPLETED:
05:00 PM
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On 4/6/21 Licensing Program Analyst (LPA) Martessa Brown conducted a Case Management Visit. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s Case Management was conducted telephonically with Miriam Rudes.

On 3/8/21 LPA Brown received a concern inquiry from reporting party (rp). She stated was not permitted to visit resident (r1) at the facility. Also, Power of Attorney has requested her not to visit visit (r1).

On 4/6/21 LPA Brown met with administrator Rudes. LPA explained prior to today’s visit had requested a copy of the poa. LPA did not receive the full poa documents. While LPA was conducting visit administrator sent a picture of a 1 page picture document of the poa. Also, LPA explained to administrator they can not refuse r1 to have visitation and will need to review PIN 21-17-ASC.

Deficiencies cited on California code of regulations title 22, division 6 chapter 1-6.

Exit Interview Conducted, appeal rights were explained and a copy of this report was furnished.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2021 04:49 PM - It Cannot Be Edited


Created By: Martessa Brown On 04/06/2021 at 04:20 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
FACILITY NUMBER: 197608859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2021
Section Cited
CCR
87506(a)

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87506 Residents Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement was not met as evidenced by:
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Administrator will submit all pages of POA to LPA Brown by POC Due Date 4/13/21.
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LPA Brown spoke to the administrator and asked for a copy of residents (r1) POA. Administrator did not have the POA in residents file. Administrator told LPA Brown to call POA to obtain a copy. This is a potential, health, safety, or personal rights risk to clients in care.
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Type B
04/13/2021
Section Cited
CCR87468(a)

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87468 Personal Rights: in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities..


This requirement was not met as evidenced by:
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Administrator will review Provider Information Notice (Pin-21-17-ASC and will submit to LPA Brown that notice on visitation has been read and understood by POC due date 4/13/21.
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Based on LPA interviews with administrators and reporting party. Resident(r1) is being denied visits at the facility. The facility is not adhering to the visit policy outline in Pin-21-17-ASC.This is a potential, health, safety, or personal rights risk to clients in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2021


LIC809 (FAS) - (06/04)
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