197609314-1-29-2026-11-AS-SCIS-DR7RFH-20260211115911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609314
Report Date: 01/29/2026
Date Signed: 01/29/2026 03:38:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2025 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251114151650

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: 6	DATE:	01/29/2026
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Miriam Rudes		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not ensure that a resident in care was receiving oxygen.
Staff did not adequately supervise a resident in care.

INVESTIGATION FINDINGS:

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On 01/29/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the above mentioned allegations and deliver findings. LPA met with Lucy Ouw, Caregiver, explained the purpose of the visit, and was granted entry to the facility.

The investigation consisted of the following: On 11/21/25, LPA Gonzalez obtained copies of the staff roster, and resident roster. LPA Gonzalez reviewed service records for resident #1 (R1) and requested the following documents: Physician’s Report, Needs and Services Plan, Admission Agreement, Death Report, Special Incident Reports, and medical records from Cedars Sinai Hospital for the visits on 09/30/25, 10/18/25. LPA Gonzalez reviewed service records for residents #2-#6 (R2-R6) and obtained copies of the following documents: Physician’s Report and Needs & Services Plan.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

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 4

Control Number 11-AS-20251114151650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEIT SHALOM GROUP LLC	FACILITY NUMBER: 197609314
	VISIT DATE: 01/29/2026

NARRATIVE

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Additionally, LPA Gonzalez interviewed staff #1-#4 (S1-S4), residents #2-#4 (R2-R4), and attempted to interview witness #1-#2 (W1-W2). LPA Gonzalez was unable to interview R1. Furthermore, LPA Gonzalez and Lucy Ouw toured the facility. On 01/29/26, LPA Gonzalez received the following records: Physician Order Form from TLC Hospice Care, Inc. (dated: 10/25/25).

The investigation revealed the following:
For the allegation: Staff did not ensure that a resident in care was receiving oxygen. It is being alleged that staff did not ensure that a resident was receiving oxygen or that the resident’s oxygen levels were appropriate. On 11/21/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff stated that they followed all physician orders and directives while caring for R1.

On 11/21/25, LPA Gonzalez conducted interviews with R2-R4 and was unable to interview R1 as they passed away on 10/28/25. Of those interviewed, 3 out of 3 residents could not corroborate with the allegation. 3 out of 3 residents stated that staff is providing the necessary care and supervision.

On 11/21/25, LPA Gonzalez conducted a review of records. Medical records from Cedars-Sinai Hospital dated 10/08/25 indicated that R1 was admitted on 09/30/25 due to swelling in the hands and legs and was discharged on 10/08/25 with diagnoses of Atrial Fibrillation (AFib) and Urinary Tract Infection (UTI). Medical records from Cedars-Sinai Hospital dated 10/25/25 noted that R1 was admitted on 10/19/25 due to low oxygen saturation levels and hypotension. R1 was discharged from the hospital on 10/25/25 under hospice care.

A review of the Unusual Incident/Injury Report (UIR) dated 09/30/25 noted that R1 was experiencing severe swelling in the hands and legs and was transported to Cedars-Sinai Hospital for evaluation. The UIR dated 10/08/25 documented that R1 returned to the facility from Cedars-Sinai Hospital on 10/08/25. The UIR dated 10/19/25 indicated that R1 was transported to Cedars-Sinai Hospital due to low oxygen saturation levels observed by staff. The UIR dated 10/25/25 noted that R1 was discharged from Cedars-Sinai Hospital and returned to the facility on 10/25/25 under hospice care with comfort-focused orders.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251114151650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEIT SHALOM GROUP LLC	FACILITY NUMBER: 197609314
	VISIT DATE: 01/29/2026

NARRATIVE

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The report further noted that R1’s oxygen saturation levels remained low upon discharge and required continuous oxygen to maintain comfort and adequate breathing. Staff ensured oxygen therapy was administered immediately upon arrival per physician and hospice orders. The UIR dated 10/28/25 noted that staff observed R1 with very low oxygen saturation levels despite continuous oxygen therapy, and R1 passed away that afternoon.

A review of the Death Report (LIC 624), dated 11/03/25, reported that R1 passed away on 10/28/25 at 5:30 p.m., with contributing factors noted as Alzheimer’s disease and decline.

On 01/29/26, LPA Gonzalez received and conducted a review of Physician Order Form from TLC Hospice Care, Inc. (dated: 10/25/25). Record revealed that R1 was prescribed oxygen inhalation as needed for shortness of breath.

Based observation, interviews conducted, and records reviewed, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is unsubstantiated.

For the allegation: Staff did not adequately supervise a resident in care. It is alleged that a resident with Diabetes was able to access a large amount of sweets at the facility without staff awareness. On 11/21/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they follow the resident’s restrictive diets. 4 out of 4 staff said residents do not have access to a large amount of candy or sweets. An interview with S1 revealed that staff supervise residents and take precautions to ensure resident safety. S1 stated that ongoing training is provided to facility caregivers and that staff attempt to follow the household menu as closely as possible. S1 reported that residents’ prescribed diets are posted above each resident’s bed and on the resident’s room door. S1 further stated that staff may advise and remind residents regarding their dietary needs; however, staff do not have control over residents’ decisions to order takeout food or purchase their own groceries, which S1 stated is the residents’ right.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20251114151650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEIT SHALOM GROUP LLC	FACILITY NUMBER: 197609314
	VISIT DATE: 01/29/2026

NARRATIVE

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On 11/21/25, LPA Gonzalez conducted interviews with R2-R4 and was unable to interview R1 as they passed away on 10/28/25. Of those interviewed, 3 out of 3 residents could not corroborate with the allegation. 3 out of 3 residents said that facility staff follow their restrictive diet. 3 out of 3 residents stated that staff is providing the necessary care and supervision.

On 11/21/25, LPA Gonzalez conducted a tour of the facility. No large quantities of sweets were observed to be accessible to residents. During the tour, LPA observed residents during lunch being served a well-balanced meal consisting of chicken, rice, and vegetables.

Based observation, interviews conducted, and records reviewed, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is unsubstantiated.

No deficiencies were cited during this investigation.

An exit interview was conducted, and a copy of the report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

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