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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600223
Report Date: 02/09/2022
Date Signed: 02/09/2022 05:54:55 PM

Document Has Been Signed on 02/09/2022 05:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 4DATE:
02/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Ecaterina Tet/Licensee-administratorTIME COMPLETED:
06:00 PM
NARRATIVE
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While at the facility investigating complaint (Complaint Control # 15-AS-20220202085410), Licensing Program Analyst (LPA) Delmundo learned that staff was tested positive of COVID-19 and report was not made to Community Care Licensing (CCL) and Local Public Health (LPH).

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Ecaterina Tet, licensee-administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/09/2022 05:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2022 at 05:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIM ASSISTED LIVING
FACILITY NUMBER: 075600223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2022
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such report. including, but not limited to, the following:(2) Ocurrences, such as epidemic outbreaks, ,,,which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile
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Licensee to review the Regulations and Provider Information Notices and ensure that a report will be made within 24 hours to CCL and LPH when facility receive a positive test result of COVID-19. Self-certification to be submitted by 2/16/2022.
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to the licensing agency and to the local health officer when appropriate.

-This requirement is not met as evidenced by:
-Based on interview and documents obtained, the licensee did not comply with the section above for not reporting when staff was tested positive of COVID-19.
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022


LIC809 (FAS) - (06/04)
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