075601505-4-19-2024-15-AS-AGOZ-D4GQBM-20240419120146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601505
Report Date: 04/19/2024
Date Signed: 04/19/2024 12:02:01 PM

Document Has Been Signed on 04/19/2024 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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:	04/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator, Alexandru Tet		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/19/2024 at 8:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Alexandru Tet and explained the purpose of the visit. The facility’s fire clearance was approved for 5 non-ambulatory with a hospice waiver for 2. LPA toured facility with Administrator, Alexandru Tet including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the residents and hallway is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/1/2022. Emergency Disaster Plan was last posted on 10/10/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/10/2023. At 8:30AM, LPA reviewed 5 residents records. At 9:00AM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 9:58 AM, LPA reviewed a sample of resident’s medications. Report Continues on LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIM ASSISTED LIVING III	FACILITY NUMBER: 075601505
	VISIT DATE: 04/19/2024

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:58 AM during file review LPA observed that there is no log available for documentation of the Residents medications and when they are taking them.
At 10:22 AM during facility tour LPA observed that S2 was residing in an area that is designated as a walkway space. The room was previously a bedroom but after renovation was deemed to be a walkway space
At 11:00 AM during facility tour LPA observed a modified structure and bathroom in the garage that is not listed on the facility sketch and no permit available.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 04/19/2024 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIM ASSISTED LIVING III	FACILITY NUMBER: 075601505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a modified structure in the garage without the proper permits which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	By POC date Administrator agrees to start the process of getting the room in the garage approved by the fire department and notify CCLD.

Type B

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not having a medication log which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to update MAR and start documenting according to regulation and notify CCLD.

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-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 04/19/2024 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIM ASSISTED LIVING III	FACILITY NUMBER: 075601505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(1)

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff... The following provisions shall apply:(1) There shall be common rooms such as ... They shall be of sufficient space and/or separation to promote and facilitate the program of activities and to prevent such activities from interfering with other functions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having S2's bedroom in an area that has been designated as a walkway which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	By POC date Administrator has agreed to remove S1 from the current area and find an appropriate space for them to live and notify CCLD.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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