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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608859
Report Date: 05/03/2022
Date Signed: 05/03/2022 04:17:39 PM

Document Has Been Signed on 05/03/2022 04:17 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
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: 4DATE:
05/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Jomar FernandoTIME COMPLETED:
04:06 PM
NARRATIVE
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On 05/3/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a Case Management - Deficiencies visit to the above facility and met with Eilat Nahum Administrator.

During investigation of complaint 11-AS-20220425152124 LPA Cifuentes noted during file review that Admissions agreements did not all include refund conditions.

Deficiencies cited on attached 809-D

A copy of this report was provided to Eilat Nahum, Licensee.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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 05/03/2022 04:17 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 05/03/2022 at 03:38 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: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87505(g)(5)(A)

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Admissions Agreement
Refund conditions. Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.
This requirement was not met as evidenced by:
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Licensee will amend admissions agreement to include details and conditions for refunds. Revised admissions agreement is due to to CCLD via fax by POC due date.
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During complaint investigation LPA reviewed records and noted that 3 out of 5 records reviewed did not have refund conditions. THis is a potential health and safety risk to the 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:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022


LIC809 (FAS) - (06/04)
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