075601505-1-6-2022-15-AS-KHOS-CBBJVD-20220204062258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601505
Report Date: 01/06/2022
Date Signed: 01/06/2022 05:30:14 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
10/26/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20211026160554

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: 6	DATE:	01/06/2022
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Alex Tet, Administrator		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Resident developed an unstageable pressure injury and suspicious marks while in care
Facility failed to provide adequate care and supervision, resulting in hospitalization
Facility failed to provide adequate hygiene

INVESTIGATION FINDINGS:

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On 01/06/22 at 5PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident developed an unstageable pressure injury and suspicious marks while in care
Investigation Finding: UNSUBSTANTIATED
During investigation, reporting party (RP) provided IB investigator pictures of what she thought were pressure sores and suspicious marks. RP stated that the hospital photographed and documented resident’s (R1) injuries when she was admitted on 10/25/2021. However, review of R1’s medical records documenting R1’s hospital stay from 10/25/2021 to 11/08/2021 do not mention any diagnosis, comments, or concerns about any scratches, skin tears, ulcers or sores. 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.

Continued on next page, LIC 9099-C

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: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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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Control Number 15-AS-20211026160554

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: 01/06/2022

NARRATIVE

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Allegation: Facility failed to provide adequate care and supervision, resulting in hospitalization
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, reporting party (RP) believed R1 was constipated which led to her bloated stomach. Staff stated R1 was not constipated because she was on stool medication (Senna 8.5 mg and Clear Lax.). Review of medical records show that in the emergency room, doctors thought R1 may have aspirated (accidental breathing in of food or fluid into the lungs) both before and during her vomiting episode in the hospital which led to the diagnosis of aspiration pneumonia. 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.

Allegation: Facility failed to provide adequate hygiene
Investigation Finding: UNSUBSTANTIATED
Based on interviews, observations and record reviews which were conducted, staff and licensee’s statements corroborated each other. Staff stated R1 was normally checked on and given either a sponge bath or shower regularly. The residents who were also interviewed did not have issues with staff either. Review of medical notes do not mention R1 having “dirty” feet as described by reporting party (RP). 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC9099 (FAS) - (06/04)

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