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Inspection visit

Routine inspection

BEIT SHALOM GROUP LLCLicense 197609314
Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Martessa Brown and Licensing Program LPM Janae Hammond conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Miriam Rudes, Administrator and the purpose of today’s visit was explained. The facility is for the elderly and licensed to serve 6 residents ages 60 and over. 5 Non-Ambulatory and 1 Bedridden only. Hospice Waiver for three. There are currently (5) Residents that are at the facility . The Facility is a single -story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, living room, kitchen and living room, laundry room, outdoor patio covered area. LPA, LPM and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115 F and bathroom #2 135 F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. During today’s visit there were no deficiencies observed. Exit interview held. A copy of the report was provided to Diana Fernando Caregiver.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(D)Type B

    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.

  • 87405(a)Type B

    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.

  • 87411(3)(c)Type B

    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.

  • 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.

FAQ · About this visit

Common questions about this visit

What happened during the January 27, 2022 inspection of BEIT SHALOM GROUP LLC?

This was an inspection of BEIT SHALOM GROUP LLC on January 27, 2022. The inspection found no deficiencies and no citations were issued.

Were any citations issued to BEIT SHALOM GROUP LLC on January 27, 2022?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

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