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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601505
Report Date: 10/04/2021
Date Signed: 10/04/2021 05:00:11 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
03/19/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20210319130013
FACILITY NAME:ELIM ASSISTED LIVING IIIFACILITY NUMBER:
075601505
ADMINISTRATOR:TET, ECATERINA & ALEXANDRUFACILITY TYPE:
740
ADDRESS:5126 CORAL COURTTELEPHONE:
(925) 689-2286
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 5DATE:
10/04/2021
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Veta Spence, CaregiverTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility does not provide a safe environment for residents.
INVESTIGATION FINDINGS:
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On 10/4/2021 at 2:40pm, Licensing Program Analysts (LPAs) L. Hall and L. Francisco arrived unannounced to conduct complaint investigation and deliver complaint findings for the above allegation. LPAs were greeted by Care Staff, Veta Spence, and explained the purpose of the visit . Administrator, Alex Tet later arrived at 3:25pm.

During the course of the investigation, LPAs interviewed staff and toured facility. Based on documents obtained facility had a flip door lock on main entrance door to the facility. LPAs observed the flip door lock during the tour of the facility. Interview with Staff 2 (S2) indicated flip door lock is used at night.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (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 3
Control Number 15-AS-20210319130013
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 III
FACILITY NUMBER: 075601505
VISIT DATE: 10/04/2021
NARRATIVE
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Continued from LIC9099.

Based on LPAs interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210319130013
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 III
FACILITY NUMBER: 075601505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2021
Section Cited
CCR
87468.1(a)(6)
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87568.1 Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Thiis requirment was not met as evidence by:
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Administrator agreed to remove flip door lock and submit a photo copy to CCLD by POC date. Flip lock was removed during visit. Deficiency cleared.
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Based on LPAs observation and interview licensee did not comply with the section cited above, which poses a potential health and safety 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3