Community Care Licensing

Document Has Been Signed on 04/16/2024 04:04 PM - It Cannot Be Edited

FACILITY NAME:	ELIZABETH CARE HOMES 2		FACILITY NUMBER:	079200869
ADMINISTRATOR/ DIRECTOR:	IME IKANEM		FACILITY TYPE:	740
ADDRESS:	1840 KERN MOUNTAIN WAY		TELEPHONE:	(925) 238-0311
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY: 6		CENSUS: 4	DATE:	04/16/2024
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Ime Ikanem, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Daisy Panlilio LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024

Link to Parent Document Below:

FACILITY NAME: ELIZABETH CARE HOMES 2	FACILITY NUMBER: 079200869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2024 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.	1 2 3 4 5 6 7	By POC due date, ADM will submit to CCL proof of administrator certificate renewal and designated substitute who has a current administrator certificate and has the qualifications adequate to be responsible and accountable for the management and administration of the facility.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by lack of presence of a certified administrator on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility which poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/13/2024 Section Cited CCR87506(c)(1)	1 2 3 4 5 6 7	All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.	1 2 3 4 5 6 7	By POC due date, ADM will submit to CCL proof of completed staff in-service retraining on how to properly handle residents’ records in compliance with Title 22 Section 87506.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by lack of confidentiality when staff mishandled resident’s confidential information as witnessed by the department’s investigator during visit on 04/2024 which posed a potential safety risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Daisy Panlilio LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024