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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608859
Report Date: 01/27/2022
Date Signed: 01/28/2022 09:13:53 AM

Document Has Been Signed on 01/28/2022 09:13 AM - 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
MONTERY 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:
01/27/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:NAOME LEIBOVTIME COMPLETED:
03:57 PM
NARRATIVE
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01/27/22 Licensing Program Analyst (LPA) Ernand Dabuet initiated a Case Management – Health Check visit. LPA was met by Naome Leibov the house manager, and explained the purpose of today’s visit.

LPA and the house manager toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.6 F. A comfortable temperature of 72 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility had a fire extinguisher that was charged, smoke detectors, and carbon monoxide was operable. LPA reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. Several working landline telephones were observed at the facility.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

Evaluation Report continues on LIC 809C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: EILAT'S MANOR
FACILITY NUMBER: 197608859
VISIT DATE: 01/27/2022
NARRATIVE
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LPA reviewed resident service records and found missing physician's reports for resident #3 and #5 (R3 - R5) and was not available for review during the inspection visit. The facility is caring for residents diagnosed with dementia and has not conducted fire drills and did not have an Emergency Disaster Plan in place. During the plant inspection, LPA observed signs posted in the kitchen area and refrigerator preventing residents' access to accommodations and equipment. LPA observed the facility did not have a current administrator on file and did not notify the Department of the change of administrator. During record review an active administrator was observe for Miriam Rudes which is not in compliance with PIN 21-24 CCLD.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiencies are issued and an exit interview is conducted with Noame Leibov. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/28/2022 09:13 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/27/2022 at 01:08 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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR
FACILITY NUMBER: 197608859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2022
Section Cited
CCR
87506(a)

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87506 Resident 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.
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The licensee will ensure that all residents have complete resident's service records which includes a physician's reports. The licensee will submit complete files for R3 and R5 by POC due date 02/10/22.
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee failed to adhere to Title 22 regulations. Licensee did not have physician's report for R3 and R5. This citation poses a potetntial health and safety risk to residents in care.
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Type B
02/10/2022
Section Cited
CCR87705(c)(2)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(2)The Emergency Disaster Plan, as required in Section 87212, addresses the safety of residents with dementia.
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The licensee will ensure that the facilty has a Emergency Disaster Plan and conducts routine fire drills with records. The licensee will submit correction by POC due date: 02/10/22.
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee failed to adhere to Title 22 regulations. The licensee did have a record of the Emergency Disaster Plan in place for review. This citation poses a potential health and safety risk to residents 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/28/2022 09:13 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/27/2022 at 01:50 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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR
FACILITY NUMBER: 197608859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2022
Section Cited
CCR
87468.1(a)(2)

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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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The licensee will adhere to Title 22 Section 87468. The licensee will perform knowledge of and conforms to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 02/10/22
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This requirement was not met as evidenced by: Based on observation and interview, the licensee had signs posted preventing residents from accessing the kitchen and refrigerator. This citation poses a potential health and safety risk to residents in care.
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This violaton was corrected during visi on 01/27/22. House manager removed posted signs and will review Title 22 section 87468.1.
Type B
02/10/2022
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator...The administrator shall have ... other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section...
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The licensee will adhere to Title 22 Section 87405. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 02/10/22 with documentation for authorized facility administrator.
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This requirement was not met as evidenced by: Based on observation and interview, the licensee did not have an authorized administrator file with CCLD. This citation poses a potential health and safety risk to residents 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2022 09:13 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/27/2022 at 02:32 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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR
FACILITY NUMBER: 197608859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2022
Section Cited
CCR
87211(g)(2)

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87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (2) Date he/she assumed his/her position.
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The licensee will send a notification in writing of change of adminsitrator with the qualified documents for certified administrator.Plan of correction will be submitted by POC due date 02/10/22.
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This requirement was not met as evidenced by: Based on interview and record reviews the Licensee failed to adhere to Title 22 regulations by reporting a change of administrator. This citation poses a potential health and safety risk to residents 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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