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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600223
Report Date: 06/06/2025
Date Signed: 06/06/2025 05:07:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220202085410
FACILITY NAME:ELIM ASSISTED LIVINGFACILITY NUMBER:
075600223
ADMINISTRATOR:TET, ECATERINAFACILITY TYPE:
740
ADDRESS:3653 WREN AVENUETELEPHONE:
(925) 689-8513
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ecaterina Tet/LicenseeTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Facility did not follow COVID-19 protocol.
INVESTIGATION FINDINGS:
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On this day, June 6, 2025, at Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Colline Osbourne, staff. LPA spoke over the phone with Ecaterina Tet, licensee, and informed the reason for visit. Licensee arrived at around.4:50 pm.

It was alleged that the licensee, Ecaterina Tet, and staff (S1) were not Covid-19 vaccinated.

During the course of investigation, LPA reviewed staff files and conducted interviews.

LPA interviewed the licensee and S1 on 2/09/22 and who both stated they were not Covid-19 vaccinated. During that period, it was required that staff including licensee shall receive Covid-19 vaccinations. Licensee was not able to provide documentation showing waivers for vaccinations. Licensee stated she just chose not to be vaccinated. Therefore, the allegation is substantiated.
.....continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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 7
Control Number 15-AS-20220202085410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELIM ASSISTED LIVING
FACILITY NUMBER: 075600223
VISIT DATE: 06/06/2025
NARRATIVE
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Page 2

Deficiency is cited from Title 22 California Code of Regulations (see 809D).

Deficiency was discussed with licensee.

Exit interview conducted. Appeal Rights and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20220202085410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIM ASSISTED LIVING
FACILITY NUMBER: 075600223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2025
Section Cited
HSC
1569.269(a)(5)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
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Facility changed legal entity.
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-This requirement is not met as evidenced by:
-Based on records review and interviews, the licensee did not ensure the personal rights of persons in care were provided safe and healthful accommodations in not following the vaccinations requirements which posed an immediate risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220202085410

FACILITY NAME:ELIM ASSISTED LIVINGFACILITY NUMBER:
075600223
ADMINISTRATOR:TET, ECATERINAFACILITY TYPE:
740
ADDRESS:3653 WREN AVENUETELEPHONE:
(925) 689-8513
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ecaterina Tet/LicenseeTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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-Staff did not follow resident's physician order.

-Licensee did not ensure that residents' medications were stored locked and inaccessible to residents.

-Staff stole residents' medications.
INVESTIGATION FINDINGS:
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On this day, June 6, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Colline Osbourne, staff. LPA spoke over the phone with Ecaterina Tet, licensee, and informed the reason for visit. Licensee arrived at around 4:50 pm.

During the course of investigation, LPA reviewed and obtained copies of residents' (R1 and R2) following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Reports; Appraisal; LIC622 Centrally Stored Medication and Destruction Records; LIC9020 Register of Facility Residents; doctor's order of medications; hospice medical records. LPA conducted inspection on 2/09/22. The following were interviewed: resident’s family member (FM1) on 2/08/22 and 7/08/22; licensee and staff (S1) on 2/09/22; staff (S2) on 7/08/22; staff (S5) on 9/22/22; staff (S3) on 9/19/23. LPA also obtained information from hospice agency staff (HH1).

....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20220202085410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELIM ASSISTED LIVING
FACILITY NUMBER: 075600223
VISIT DATE: 06/06/2025
NARRATIVE
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Page 2

Allegation: Staff did not follow resident's physician order.
FM1 stated that resident (R1) had a physician's order to have secretions sucked from R1’s throat however, on 1/31/2022, the licensee told RP that staff did not follow the resident's physician's order because the licensee and staff were too sick with COVID to properly care for R1.

The licensee confirmed she tested positive during that time. She stated she isolated, and that S2 and S3 assisted during that period. S3 confirmed he and S2 assisted. S3 stated that the licensee is a Licensed Vocational Nurse and that S2 showed S3 how to do the suctioning of R1 in the mouth. S2 walked him through it. S5 stated there were times when R1 has 'whizzle' and when it happened there was someone who came and suctioned R1. S5 further stated that if the licensee was around, the licensee did the suctioning.

HH1 stated that a suction machine was ordered during R1’s admission for hospice care on 7/14/21, and that during admission, R1’s wife (FM2) and FM1 reported a history of persistent coughing, swallowing difficulties, and the need for increased suctioning. HH1 further indicated that the respiratory issue stemming from aspiration were managed with antibiotics, breathing treatments and oral suctioning, and that due to the ongoing high risk for aspiration pneumonia, intermittent suctioning is necessary for congestion episodes, with PRN nebulizer use. HH1 stated that there were in-person visits where the hospice registered nurse performed suctioning. HH! further indicated that suctioning was also managed by the facility and the staff were expected to perform oral suctioning, while hospice nurses can perform tonsillar suctioning. No one performed deep bronchial suctioning as this is beyond the scope of hospice care. LPA tried to obtain information from FM2 but unsuccessful.

Based on information gathered, the allegation is unsubstantiated.

Allegation: Licensee did not ensure that residents' medications were stored locked and inaccessible to residents.


FM1 stated that former staff stole medications from unlocked cabinet in the kitchen. During inspection, LPA observed the medications were centrally stored in the cabinet in the kitchen which was locked.

.....continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20220202085410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELIM ASSISTED LIVING
FACILITY NUMBER: 075600223
VISIT DATE: 06/06/2025
NARRATIVE
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Page 3

S5 stated the licensee has the key to the central medication storage and if the licensee was out on vacation, S2 and S3 had the key. S3 stated that S5, S6 and S7 had access to the medication and the central storage was always locked. LPA was unable to obtain information from S6 and S7. Therefore, the allegation is unsubstantiated.

Allegation: Staff stole residents' medications.
FM1 stated that medications were stolen by S6 and S7. The licensee denied the allegation. S1 stated the medications had never gone missing. S2 stated he heard about the allegation but the medications were never stolen nor gone missing. S3 stated S5, S6 and S7 had access to the medications cabinet but medications were never stolen or gone missing. S5 stated she was not aware of it and added that it is impossible for medications to be stolen, because the cabinet was always locked. LPA was not able to obtain information from S6 and S7. Therefore, the allegation is closed as unsubstantiated.

Based on all information obtained, all 3 allegations were unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or were valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.



Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220202085410

FACILITY NAME:ELIM ASSISTED LIVINGFACILITY NUMBER:
075600223
ADMINISTRATOR:TET, ECATERINAFACILITY TYPE:
740
ADDRESS:3653 WREN AVENUETELEPHONE:
(925) 689-8513
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ecaterina Tet/LicenseeTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Licensee did not delegate a substitute during absence from facility.
INVESTIGATION FINDINGS:
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On this day, June 6, 2025, at Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Colline Osbourne, staff. LPA spoke over the phone with Ecaterina Tet, licensee, and informed the reason for visit. Licensee arrived at around 4:50 pm.

During the course of investigation, LPA the following staff were interviewed: licensee and staff (S1) on 2/09/22; staff (S2) on 7/08/22; staff (S5) on 9/22/22; staff (S3) on 9/19/23. All these staff stated that when licensee was out, S2 came and worked. Review of Active Certificate List on Community Care Licensing website showed S2 was a certified administrator when complaint was received. S2's administrator certificate was renewed upon expiration and is currently active. Therefore, the allegation is unfounded.

No deficiency cited.

Exit interview conducted and copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7