SHALOM HOUSE

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

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... This requirement is not met as evidenced by: Licensee did not comply with the section cited above. Licensee did not ensure that they have an active Administrator Certificate which posed/poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to provide LPA with an update regarding the following items: submitting their paperwork via the Application Portal, communicating with the Application Unit regarding their application status, and hiring an Administrator. Update to be provided to LPA by POC Due Date 3/9/2026 by 5:00PM.

Deadline recorded: Mar 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

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... This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made and interview conducted, Licensee did not comply with the section cited above. Licensee did not ensure that they have an active Administrator Certificate. Licensee’s last administrator certification was December 2021. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee to provide LPA with an update regarding the following items: submitting their paperwork via the Application Portal, communicating with the Application Unit regarding their application status, and hiring an Administrator. Update to be provided to LPA by POC Due Date of 11/04/2025.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

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... This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made and interview conducted, Licensee did not comply with the section cited above. Licensee did not ensure that they submitted an application to renew their Administrator’s Certification with the Department. Licensee’s last administrator certification was December 2021. This regulation poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 11/04/2024 Plan of Correction Licensee to submit renewal application to Department immediately and notify LPA once they are on the pending renewal list. During visit, LPA observed Licensee begin to fill out renewal application.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidenced by: Based on interview conducted and record review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee provided copy of Death Report for R1 during visit. Licensee to submit self-certification stating that they understand the regulation requiring that reports are submitted timely to the Department by POC due date of 07/21/2024.

Deadline recorded: Jul 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview with Administrator and record review, the licensee did not comply with the section cited above in 2 out of 4 staff files do not contain required health screening report or TB test verification, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2023 Plan of Correction Licensee to have Staff (S1) & (S2) obtain a health screening with TB test and submit copies to Community Care Licensing for review by POC due date 10/27/2023. Licensee to notify CCL if more time is needed.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the administrator did not comply with the section cited above in 3 out of 3 staff do not initial training required and or on going training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2023 Plan of Correction Facility to ensure that all facility & agency staff have initial training required as well as on going training. Facility to provide CCLD with a plan on how facility will ensure that all staff have required training on file as well as how it will maintain the on going training and self certification that staff has all training required to be reviewed by the Department by POC date of 10/27/23 in order to clear this citation.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the administrator did not comply with the section cited above in 1 out of 1 facilty quarterly disaster drills were not conducted which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator stated that there is no proof of drill, we have not been doing.

Official plan of correction

POC Due Date: 10/20/2023 Plan of Correction Facility to ensure that facility will conduct quarterly disaster drills as required by Health & Sfety Code. Administrator to submit to CCL proof of disaster drill conducted wiht the facility by POC date of 10/20/2023.

Official classification

Type B

Official code

85095.5(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not having or aware that the facdility needs an Infection Control Plan which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2023 Plan of Correction Administrator will provide and Infection Control Plan to CCL no later than the POC date.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

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. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. 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. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview the administrator did not comply with this section above due to Licensee's Administrators Certificate expired December, 2022. This regulation poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2023 Plan of Correction Licensee shall provide WEEKLY updates regarding obtaining an updated Administrators Certificate. Furthermore, Licensee shall submit a plan for future compliance and an LIC 9098-Self Certification form.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance- 87355(e)(1)- All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's review of staff associations list from Departments LIS Data Base, and review of DOJ Fingerprint Lists/Clearance Information in the Guardian website. Licensee stated to the LPA that she did not follow-up on Leticia Reye's fingerprinting documentation and/or ensure she had fingerprint clearance & has worked in the facility since 9/1/2023. This is a personal rights/Health and Safety violation and risk to all residents in care. An immediate Civil Penalty will be assessed in the amount of $500-see LIC421BG.

Official plan of correction

POC Due Date: 10/13/2023 Plan of Correction Licensee/Administrator to have the individual/Susan Nyambura get fingerprinted and obtain criminal record clearance. The individual can't return to work and/or be on facility premises until criminal record clearance is obtained and/or a criminal record clearance exemption is granted. Licensee/Administrator stated her understanding of the regulation and information stated above. Licensee to submit facility policy and procedures regarding hiring staff and fingerprint clearance requirements, and plan in ensuring compliance with the regulation. POC due 10/13/23.