197609314-12-23-2024-11-AS-RORN-DCX2BJ-20250114161513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609314
Report Date: 08/28/2024
Date Signed: 12/23/2024 08:26:08 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20231018105832

FACILITY NAME:	BEIT SHALOM GROUP LLC		FACILITY NUMBER:	197609314
ADMINISTRATOR:	RUDES, MIRIAM		FACILITY TYPE:	740
ADDRESS:	1620 S SHERBOURNE DRIVE		TELEPHONE:	(213) 222-7598
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 5	DATE:	08/28/2024
		UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Ina Hamsiah		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not ensure resident received his cash resources

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, August 28, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff Ina Hamsiah and spoke to the Licensee Miriam Rudes via telephone. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: Interviews conducted with staff members 1-2 (S1-S2) and residents 2-5 (R1-R5). S1 stated that the resident received all cash resources but would leave the facility for days without picking up the checks. S2 stated that she was not aware of the incident, as she did not work at the facility during that time. LPA Bunker reviewed and observed the resident's records and requested copies of supporting documents.

See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20231018105832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM GROUP LLC	FACILITY NUMBER: 197609314
	VISIT DATE: 08/28/2024

NARRATIVE

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Continued LIC9099-C page 2

Allegation: Staff did not ensure that the resident received his cash resources

Interviews were conducted with staff members S1 and S2, as well as residents R1 through R5. who stated that residents received all their cash resources.

S1 stated that R1 received all cash resources and explained that she provided R1 with his checks, which he refused to pick up. S1 further stated that R1 had a bank account with Bank of America, where R1 SSI checks were deposited. S1 stated that R1 was not cashing the checks and would often leave the facility for several days or weeks. S1 denied owing R1 $3,000.00, referencing a letter from R1 stating, “To tell you the truth, I straight forgot about them. Please send me another set.” S1 stated that R1 provided a new mailing address, and the checks were sent to R1's current address. S1 stated that R1 moved out in March 2023. S1 stated that this incident occurred two years ago and was reported to Community Care Licensing and other appropriate agencies in a timely manner. S1 stated that the issue had been resolved. Residents 2-5 (R2-R5) stated they had no issue with their cash resources, as their family members handled their finances.

In an interview with R1, he admitted to receiving cash resources and stated that the complaint was made out of frustration and anger. R1 acknowledged that all money was received and that the issue had since been resolved prior to the complaint.

LPA Pamela Bunker requested, observed, and conducted a thorough review of the resident's file folder, including the physician's report, medical records, admission agreement, identification and emergency information, contact information, medication log, Medication Administration Records (MARs), medical assessment, consent forms, release of resident medical information, appraisal/needs and services plan, safeguards for cash resources, preplacement appraisal information, unusual incident reports, copies of the SSI checks, and the letter from R1 dated 09/12/2023.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20231018105832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEIT SHALOM GROUP LLC	FACILITY NUMBER: 197609314
	VISIT DATE: 08/28/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Continued LIC9099-C page 3 Due to time constraints, LPA was unable to complete the visit and will return back at a later date to complete the visit. Copies of the Complaint Investigation Report LIC9099 and LIC9099-Cs were provided to staff. There were no deficiencies cited. Exit interview conducted

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3