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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601505
Report Date: 05/25/2023
Date Signed: 05/25/2023 11:15:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
05/10/2023 and conducted by Evaluator Paris Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230510082314
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: 6DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Samuel Tet
Ecaterina Tet, Administrator		TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff installed an inappropriate lock on facility door.
INVESTIGATION FINDINGS:
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On 5/25/2023 at 9:45 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to deliver findings for the above allegations. LPA met with Administrator, Ecaterina Tet and Samuel Tet, and explained the purpose of the visit.

During the course of the investigation, LPA P. Watson obtained information, reviewed records, collected documents, interviewed staff, and family members. It was alleged that Staff installed an inappropriate lock on facility door. Based on observations, facility reversed the deadbolt lock of the exterior door, making the door unable to be opened from the inside unless a key is used. Based on interviews with Administrators, the facility had the lock reversed due to residents getting out at night. On 5/17/2023 the Administrator, Alexandru Tet, removed the deadbolt lock and replaced it with a door hole cover.

Report continues on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
05/10/2023 and conducted by Evaluator Paris Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230510082314

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: 6DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Samuel Tet
Ecaterina Tet, Administrator		TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff restricts visiting hours to residents.
INVESTIGATION FINDINGS:
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On 5/25/2023 at 9:45 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to deliver findings for the above allegation. LPA met with Administrator, Ecaterina Tet and Samuel Tet, and explained the purpose of the visit.

During the course of the investigation, LPA P. Watson obtained information, reviewed records, collected documents, interviewed staff, and family members. It was alleged that Staff restricts visiting hours to residents. Based on observations, the facility has visitor hours posted near the front door that states 10AM-12PM and 3PM-7PM. Based on interviews with family members (F1, F2, F3, F4, F5 and F6) facility does not have restrict visiting hours, the facility is flexible with family members.

Report continues on 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 5
Control Number 15-AS-20230510082314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELIM ASSISTED LIVING III
FACILITY NUMBER: 075601505
VISIT DATE: 05/25/2023
NARRATIVE
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F4 and F6 stated that they typically pick up their family member for medical appointments and/or outing and have arrived as early as 8:00 AM without any issues or complaints. F1 and F3 stated that they just show up to the facility, within reasonable hours, and are always welcomed by staff. F3 also stated that the facility does not stick to the visiting hours posted, and that staff have always accommodated them whenever they have visited outside of the of the posted hours. Based on interview with Administrator, Ecaterina, families are more than welcome to come anytime, and residents are always going places with their families.

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.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230510082314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIM ASSISTED LIVING III
FACILITY NUMBER: 075601505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2023
Section Cited
CCR
87468.1(a)(6)
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 Personal Rights of Residents in All...
(a)Residents in all residential care facilities for the elderly 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...
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Deficiency cleared during initial 10-day investigation on May 17th, 2023. Administrator removed deadbolt lock and replaced it with door hole cover.
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 Based on observation and interviews, the licensee reversed the deadbolt lock of the exterior door, making the door unable to be opened from the inside unless a key is used which poses/posed a potential Health, Safety or Personal Rights 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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230510082314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELIM ASSISTED LIVING III
FACILITY NUMBER: 075601505
VISIT DATE: 05/25/2023
NARRATIVE
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Based on LPA observations and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5