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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200869
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:53:06 PM

Substantiated


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
08/21/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230821110142
FACILITY NAME:ELIZABETH CARE HOMES 2FACILITY NUMBER:
079200869
ADMINISTRATOR:IME IKANEMFACILITY TYPE:
740
ADDRESS:1840 KERN MOUNTAIN WAYTELEPHONE:
(925) 238-0311
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ime Ikanem, Administrator
Perla Agpalasin, Staff		TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff allowed resident to leave the facility unassisted
INVESTIGATION FINDINGS:
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On 08/31/23 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit, met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on his behalf and sign the reports. LPA explained the purpose of the visit with staff (S1, ADM) and delivered investigation findings.


Allegation: Staff allowed resident to leave the facility unassisted
Investigation Finding: Substantiated
During investigation, staff (ADM, S1) confirmed with LPA that resident (R1) went out of the facility without the knowledge of staff on several dates (04/08/23, 08/19/23, 08/20/23,08/23/23).

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 3
Control Number 15-AS-20230821110142
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: ELIZABETH CARE HOMES 2
FACILITY NUMBER: 079200869
VISIT DATE: 08/31/2023
NARRATIVE
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Review of R1’s physician’s report dated 10/26/22 showed R1 was not allowed to leave the facility unassisted. Staff (ADM, S1) stated R1 was not reappraised by staff nor re-evaluated by his primary care physician to address his elopement behaviors. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff allowed resident to leave the facility unassisted is found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.
Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230821110142
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: ELIZABETH CARE HOMES 2
FACILITY NUMBER: 079200869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87463(b)
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Re-appraisal
The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person
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By POC due date, Administrator agrees to complete and submit to CCL in-service staff retraining certifications on re-appraisal of resident to timely address any change in condition in compliance with
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This requirement was not met as evidenced by staff allowing resident to leave the facility unassisted which posed a potential health and safety risk to resident in care.
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Title 22 Section 87463 (b).
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3