198320323-6-19-2025-11-AS-EMAZ-DJA5LQ-20250704200333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320323
Report Date: 06/19/2025
Date Signed: 06/19/2025 02:33:04 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
06/10/2025 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20250610105940

FACILITY NAME:	BEIT SHALOM		FACILITY NUMBER:	198320323
ADMINISTRATOR:	NAHUM, EILAT		FACILITY TYPE:	740
ADDRESS:	3121 CASTLE HEIGHTS AVE		TELEPHONE:	(310) 309-0405
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS: 5	DATE:	06/19/2025
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Shimmy Bayar		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff does not provide adequate supervision resulting in resident falling on multiple occassions.
Staff did not meet resident's care needs resulting in UTI.

INVESTIGATION FINDINGS:

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On 06/19/25, Licensing Program Analysts (LPA), Antonine Richard, conducted an unannounced complaint visit to the facility listed above. LPA met with Designee Administrator Eilat Nahum and conducted an interview over the phone with Administrator Shimmy Bayar. The purpose of today’s visit was explained.

During today’s visit, LPA conducted a facility inspection and interviewed Residents R2-R6, as well as Staff S1-S3. The following documents were reviewed and obtained: Staff Roster, Resident Roster, and documents for R1, including the Physician Report dated 04/14/25, the Admission Agreement dated 05/03/25, the Resident Appraisal dated 04/02/25, and Unusual Incident Reports dated 05/11/25, 05/19/25, 05/20/25, 05/23/25, 05/30/25, and 06/09/25. Facility notes dated 05/07/25 through 06/10/25, along with 40 hours of staff training in Behavior Management Training, Fall Prevention, and Safety Protocols dated 03/11/25, and 40 hours of training in Activities of Daily Living (ADLs) support dated 02/11/25, were also reviewed. Additionally, Hospital Discharge documents dated 05/24/25 and from 06/06/25 to 06/07/25 were obtained. Furthermore, documents pertinent to the investigation were reviewed and acquired.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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-20250610105940

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	FACILITY NUMBER: 198320323
	VISIT DATE: 06/19/2025

NARRATIVE

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Allegation #1: Staff does not provide adequate supervision, resulting in residents falling on Multiple occasions.

The complaint alleges that the staff did not provide adequate supervision for the resident, which resulted in the resident falling three times and requiring hospitalization.

On June 19, 2025, between 9:30 AM and 11:00 AM, the LPA interviewed Administrator #1 (A1), who denied the allegations. A1 stated that they ensured all residents received adequate supervision and provided the necessary training to facility staff to care for the residents effectively.

During the same time frame, the LPA interviewed three staff members (S1, S2, S3). All three staff members denied the allegations and asserted that they consistently provided supervised care for Resident #1 (R1) daily.

Later, on June 19, 2025, between 11:30 AM and 12:30 PM, the LPA interviewed five residents (R2, R3, R4, R5, R6). All five residents denied the allegations and stated that the staff took good care of them.

Records reviewed from R1’s medical discharge papers from Olive View Medical Center indicated that R1 fell on May 24, June 6, and June 7, 2025, but sustained no injuries.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20250610105940

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	FACILITY NUMBER: 198320323
	VISIT DATE: 06/19/2025

NARRATIVE

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On June 19, 2025, records reviewed indicated that staff completed 40 hours of training in Fall Prevention and Safety Protocols, as well as in the use of medical equipment, including walkers, wheelchairs, and other devices that assist residents in their daily activities. The LPA observed one resident walking with a walker, assisted by staff, and another resident in a wheelchair, with staff present and ready to assist.

The LPA also reviewed R1's Appraisal/Needs and Services Plan, which did not indicate that R1 was considered a fall risk. And does not need assistance walking. LPA could not interview resident R1 because R1 is no longer living at the facility.

Based on the LPA observations, interviews, and record reviews, the preponderance of evidence has not been met. Although the allegation may have happened or is valid, there is insufficient evidence to prove whether the alleged violation did or did not take place; therefore, the allegation is unsubstantiated.

Allegation #2: Staff did not meet the resident’s care needs, resulting in UTI.

The complaint alleges that the facility is failing to provide proper care for Resident #1 (R1), leading to a urinary tract infection (UTI). R1 had to be hospitalized due to an accidental fall. On June 19, 2025, between 9:30 AM and 11:00 AM, the Licensing Program Analyst (LPA) interviewed Administrator #1 (A1), who denied the allegations. A1 stated that all residents receive 40 hours of training in Activities of Daily Living (ADL) Support, as well as Best Practices for Hygiene and Personal Care.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20250610105940

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	FACILITY NUMBER: 198320323
	VISIT DATE: 06/19/2025

NARRATIVE

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During the same time frame, the LPA also interviewed three staff members (S1-S3). All three staff members denied the allegations and stated that they continuously assist R1 with hygiene and personal care. They also stated that they regularly change the resident R1 diapers.

Later, on June 19, 2025, between 11:30 AM and 12:30 PM, the LPA interviewed five residents (R2-R6). All five residents denied the allegations, asserting that the staff provides them with good care.

A review of the Preplacement and Service Plan indicated that R1 does not require assistance with meal consumption and walking. Additionally, interviews with three staff members revealed that they encourage residents to stay hydrated and provide water. Record reviews showed that staff received in-service training on infection control and prevention on March 7, 2025. Furthermore, five resident interviews confirmed that staff ensure residents drink plenty of water.

LPA also interviewed with three residents who reported that staff change their diapers every two hours and as needed. The LPA observed water stations in the kitchen, living room, dining room, and bottled water available in residents' rooms. LPA could not interview resident R1 because R1 is no longer living at the facility.

Regarding the allegation that staff did not meet the resident's care needs, resulting in a UTI, the Department found no evidence to support the claim. Based on record reviews, interviews, and observations. Although the allegations may have happened or is valid, there is not enough evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

No deficiencies were cited. Exit interview conducted. A copy of this report was provided to the staff Freddie Brown.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4