075601505-10-4-2021-15-AS-KHOS-C7QL3M-20211012082411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601505
Report Date: 10/04/2021
Date Signed: 10/04/2021 04:32:06 PM

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
09/24/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210924150107

FACILITY NAME:	ELIM ASSISTED LIVING III		FACILITY NUMBER:	075601505
ADMINISTRATOR:	TET, ECATERINA & ALEXANDRU		FACILITY TYPE:	740
ADDRESS:	5126 CORAL COURT		TELEPHONE:	(925) 689-2286
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 5	DATE:	10/04/2021
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Alex Tet, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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8
9

Staff are refusing to transport resident to get vaccine

INVESTIGATION FINDINGS:

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2
3
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5
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7
8
9
10
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13

On 10/4/2021 at 2:40pm, Licensing Program Analyst (LPA) L. Francisco and L. Hall arrived unannounced to conduct complaint investigation for the above allegations. LPAs were greeted by Care Staff Veta Spence. Administrators, Alex Tet later arrived at 3:25pm.

During the complaint investigation, LPAs obtained information, reviewed records and interviewed staff. It was alleged by complainant that staff are refusing to transport resident to get vaccine. Based on record review of R1's admission agreement, it indicates R1's family is responsible for transportation and if family is unable to, facility will make arrangement with public transportation. S1 and S2 stated if R1 does not have transportation for R1's vaccine appointment, facility will provide transportation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

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 2

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
09/24/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210924150107

FACILITY NAME:	ELIM ASSISTED LIVING III		FACILITY NUMBER:	075601505
ADMINISTRATOR:	TET, ECATERINA & ALEXANDRU		FACILITY TYPE:	740
ADDRESS:	5126 CORAL COURT		TELEPHONE:	(925) 689-2286
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 5	DATE:	10/04/2021
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Alex Tet, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is charging resident for hygiene supplies

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/4/2021 at 2:40pm, Licensing Program Analysts (LPAs) L. Francisco and L. Hall arrived unannounced to conduct complaint investigation for the above allegations. LPAs were greeted by Care Staff Veta Spence. Administrators, Alex Tet later arrived at 3:25pm.

During the complaint investigation, LPAs obtained information, reviewed records and interviewed staff. Based on information obtained, facility is charging resident for hygiene suppies due to incontinence. Interview with 2 of 2 staff revealed R1's Medi-Cal covers R1's incontinence supplies. Staff stated facility does not charge residents for the standard hygiene supplies.

This agency has investigated the complaint alleging facility is charging resident for hygiene supplies . We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2