075601505-12-17-2021-15-AS-KHOS-CA4LTK-20211227080227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601505
Report Date: 12/17/2021
Date Signed: 12/17/2021 11:03:22 AM

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
10/28/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20211028113645

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:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alex Tet, Administrator		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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On 12/17/21 at 9:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent complaint visit, met with administrator and explained the purpose of the visit. LPA observed 2 staff wearing face masks and 2 residents watching TV during visit.

Based on interviews and record reviews, resident's (R1) signed safeguard of property and valuables dated 06/26/18 did not show any items to declare. Staff (administrator & S1) stated all of R1's belongings were picked up by her authorized representative on 11/15/21. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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

LIC9099 (FAS) - (06/04)

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