Beit Shalom Group Llc

Authority to audit and copy facility records

87755 Inspection Authority of the Licensing Agency. (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met as evidence by: an attempted reocord review. LPA was unable to gain access to records during an investigation due to administration or a designee being onsite or available by phone.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...shall be on the premises a sufficient number of hours to permit ... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.... This requirement was not met as evidence by: Based on interview w/ caregiver, the facility will be without administration until Wednesday. This poses a potential health and safety risk to residents in care.

Certified administrator requirements and substitute coverage

87405Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities ..This requirement is not met as evidence by: Based on observation and record reviews the Administrator Miriam Rudes did not have a current Administrator Certificate or an Administrator wavier on file.This poses a potential health and safety risk to residents in care.

Maintain physician order documentation in resident record

87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance.. 3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...This requirement is not met as evidence by: LPA observed bed rails on R#2's bed. LPA reviewed residents files and did not see an exception for R2 to have bed rails.This poses a potential health and safety risk to residents in care.

87411 Personnel Requirements - General(3) The training shall include, but not be limited to, the following: (c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter.This requirement is not met as evidence by: Based on observation LPA did not observed current training records for Staff #1-2. This possess a potential health and safety risk to residents in care.This posses a potential health and safety risk to residents in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidence by: During LPA's interview conducted with administrator and police officer. Administrator did not submit and incident report to LPA regarding R1's incident that took place prior to visit.This posses a potential health and safety risk to residents in care.

87468.1(3) - (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met by: Based on observations nad interviews resident transferred rooms without permission.

T80072(a)2-to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This was requirement was not met as evidence by: Based on obeservations and interviews They did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke, they still did not take them to doctor appointments. Which poses a potential health safety to persons in care.

80061(d)(f) -The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.This was quirement was not met as evidence by: Based on observations and interviews previous email showing communication with previous Case Manager about medication, stroke, and missed doctor visits. Administrator never produced the emails and could not remember Case Managers name. Which poses a potential health, safety to persons in care.

80075(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.This was quirement was not met as evidence by: Based on obeservations and interviews They did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke, they still did not take them to doctor appointments. Which poses a potential health safety to persons in care.

80075(b)5(B) Once ordered by the physician the medication is given according to the physician's directions.This was quirement was not met as evidence by:Based on obeservations and interviews for a couple months around midyear of 2020 medication was not being given to R#1, because insurance did not cover the medication. Which poses a potential health, safety to persons in care.

85064(j)4 - Provision of, or insurance of the provision of, services to the clients, required by applicable law and regulation, including those services identified in the client's individual needs and services plans. This was quirement was not met as evidence by: Based on obeservations and interviewsthey did not take R#1 to doctor’s appointments because he refused to go into the doctor’s office. Even thought, R#1 had suffered a stroke, they still did not take them to doctor appointments. Which poses a potential health, safety to persons in care.

85068.3(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.This was quirement was not met as evidence by: Based on observations and interviews R#1 had suffered a stroke. Which poses a potential health, safety to persons in care.