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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600223
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:17:30 PM

Document Has Been Signed on 02/11/2022 02:17 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: 3DATE:
02/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ecaterina TetTIME COMPLETED:
02:25 PM
NARRATIVE
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On 2/11/22 at 12:50 PM, LPAs Jill Clancy-Czuleger and Lizette Francisco arrived unannounced to conduct a case management visit pertaining to information obtained by LPA A. Delmundo from the visit on 2/9/22. LPAs met with the Administrator and explained the purpose of the visit.

On 2/9/22, LPA A. Delmundo was informed that the facility had an outbreak of Covid-19 on 1/6/22. Based on record review and interview with Administrator on 2/11/22, no incident report was submitted to CCLD. Administrator confirmed that no call was made to licensing. During an interview with Administrator it was revealed that the facility is not meeting the weekly Covid-19 testing requirement for unvaccinated staff.

LPAs advised Administrator to maintain a medical exemption record for unvaccinated staff.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/11/2022 02:17 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 02/11/2022 at 01:28 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: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2022
Section Cited
CCR
87405(d)(2)

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Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met by evidenced by:
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Administrator agrees to review PIN 21-53 and PIN 21-44-ASC. By POC date, Administrator will submit a copy of medicat exemption and a copy of scheduled PCR test, and submit a copy to CCL.
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Based on interview and record review, licensee did not comply with the regulation cited above. Administrator confirmed Covid-19 weekly testing for unvaccinated staff has not been occurring. Which poses an immediate health and safety risk for persons in care.
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Type A
02/14/2022
Section Cited
CCR87211(a)(2)

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Reporting Requirements
(2) Occurrences, such as epidemic outbreaks... shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate

This requirement is not met by evidenced by
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By POC date administrator agrees to review regulation and submit self certification letter of acknowledgement to CCL.
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Based on interview and record review licensee did not comply with the regulation cited above. Administrator confirmed they did not inform CCL that they had Covid-19 outbreak Which poses an immediate health and safety risk for 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/11/2022 02:17 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 02/11/2022 at 01:48 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: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
87211(a)(1)

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Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...


This requirement is not met by evidenced by
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By POC date administrator agrees to review regulation and submit self certification letter of acknowledgement, and incident report to CCL
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Based on record review licensee did not comply with the regulation cited above. Administrator did submit incident report to CCL that they had Covid-19 outbreak which poses a potential health and safety risk for 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022


LIC809 (FAS) - (06/04)
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