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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200869
Report Date: 07/01/2025
Date Signed: 07/01/2025 03:09:19 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
02/06/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240206140145
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:0CENSUS: 4DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marivel Calambro, Administrator
Henry Sevilla, Co-Administrator		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure resident was rotated resulting in resident developing multiple pressure injuries
Staff did not ensure resident was being fed resulting in malnutrition
Staff did not provide responsible party incident reports as requested
Staff did not provide adequate care and supervision resulting in resident sustaining an injury
INVESTIGATION FINDINGS:
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On 07/01/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the Department obtained the following documents from administrator: staff roster with contact information, LIC500, resident roster, admission agreement, physician's report, preplacement appraisal, care plan, emergency information, responsible party (POA) information, hospital discharge summary reports, Home Health reports, police report, incident reports, death report, and medication administration records (MARs). LPA conducted a Health & safety check on 2/7/2024.
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: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 9
Control Number 15-AS-20240206140145
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: 07/01/2025
NARRATIVE
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Allegation: Staff did not ensure resident was rotated resulting in resident developing multiple pressure injuries
Investigation Finding: Substantiated
During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & R1’s responsible party (POA) and reviewed R1’s documents. Review of R1’s records showed he was admitted at the facility on 04/01/2023 and resided at the facility until 12/30/23. R1 was assessed as having dementia, non-ambulatory, needs assistance transferring in & out of bed, on a special diet of pureed foods and did not have a history of skin breakdown. On 12/31/2023, R1 was admitted at the hospital for treatment of acute kidney injury. While at the hospital, R1 was diagnosed with a total of 2 unstageable pressure injuries on his left and right heel. S2 confirmed with the department that she was aware of R1’s pressure injuries on his left and right heel but did not report her findings to the administrator (ADM) and licensee or other staff (S1) because R1’s injuries were already healed. R1’s responsible party (POA) stated that R1 sustained another pressure injury on his butt in October 2023 while at the facility. Staff notified her of the small pressure injury on R1’s butt and instructed her to buy cream to help the pressure injury heal. It was also found that R1 was receiving home health services for physical therapy but was not receiving wound care. R1 started receiving wound care on 12/31/2023 when he was diagnosed with unstageable pressure injuries at the hospital. Based on the Department’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 did not ensure resident was rotated resulting in resident developing multiple pressure injures was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in developing multiple pressure injuries while in care. Additional civil penalty related to serious bodily injury is pending review.

Continued on next page, LIC 9099-C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 15-AS-20240206140145
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: 07/01/2025
NARRATIVE
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Allegation: Staff did not ensure resident was being fed resulting in malnutrition
Investigation Finding: Substantiated
During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical records dated 12/31/2023 showed that he was admitted to the emergency room (ER) hospital with a diagnosis of malnutrition and wound care. POA stated that Emergency Room (ER) documented R1 had open wounds on his feet, between the knees and a large area on his backside which were not reported by staff to R1’s POA and PCP. On admission to the Skilled Nursing Facility (SNF) on 01/06/2024, R1’s weight was 75 pounds His initial weight on admission to the facility on 04/01/2023 had been 100 pounds. Based on the Department’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 did not ensure resident was being fed resulting in malnutrition was found to be substantiated.

Allegation: Staff did not provide responsible party incident reports as requested
Investigation Finding: Substantiated
During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Witness (W1) stated that on 12/31/2023 R1 was hospitalized with a diagnosis of sepsis and wound care. R1 was treated and transferred to a SNF on 01/06/2024. An email was sent to the ADM advising him that R1 was in a SNF and that a copy of the LIC 624 unusual incident report submitted to Community Care Licensing (CCL) for R1 was needed. W1 stated they received an email from ADM on 01/13/2024 that they would send the LIC624 right away. As of 01/24/2024, no incident report (LIC624) on R1 has been received from ADM. Based on the Department’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 did not provide responsible party incident reports on R1 as requested was found to be substantiated.

Continued on next page, LIC 9099-C pg3
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 15-AS-20240206140145
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: 07/01/2025
NARRATIVE
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Allegation: Staff did not provide adequate care and supervision resulting in resident sustaining an injury
Investigation Finding: Substantiated
During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s physician’s report dated 05/31/2023 showed he was diagnosed with Dementia and did not have sepsis, skin conditions or pressure injuries when he was first admitted at the facility on 04/01/2023. POA stated that ER hospital documented R1’s open wounds on his feet, between the knees and a large area on his backside on 12/31/2023 which were not reported by staff to R1’s POA and PCP prior to R1’s hospitalization. Based on the Department’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 did not provide adequate care and supervision resulting in resident sustaining an injury was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Additional civil penalty related to serious bodily injury is pending review.

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

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
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
02/06/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240206140145

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:0CENSUS: 4DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marivel Calambro, Administrator
Henry Sevilla, Co-Administrator		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff neglected resident resulting in multiple hospitalizations
Staff overmedicated resident in care
Staff did not monitor resident’s change of health conditions
INVESTIGATION FINDINGS:
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5
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10
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13
On 07/01/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the Department obtained the following documents from administrator: staff roster with contact information, LIC500, resident roster, admission agreement, physician's report, preplacement appraisal, care plan, emergency information, responsible party (POA) information, hospital discharge summary reports, Home Health reports, police report, incident reports, death report, and medication administration records (MARs). LPA conducted a Health & safety check on 2/7/2024.
Continued on next page, LIC 9099-C pg 4
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 15-AS-20240206140145
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: 07/01/2025
NARRATIVE
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Allegation: Staff neglected resident resulting in multiple hospitalizations
Investigation Finding: Unsubstantiated
During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 lived at the facility from 04/01/2023 until 12/30/2023. He passed away at a SNF on 01/12/2024. Based on interviews and record reviews, R1 was hospitalized four times while in care at the facility from 04/09/23 until 04/13/23 due to pneumonia; on 04/23/2023 to 06/05/2023 due to congestion; 09/17/2023 to 09/21/2023 due to sepsis with pneumonia and acute respiratory failure, 12/20/2023 due to laceration on his forehead (came back to the facility the same day) and on 12/30/2023 due to low blood pressure and labored breathing. Staff denied neglecting R1’s care while at the facility. Staff (S1, S2, S3) stated they assisted R1 with his activities of daily living such as assisting him with eating his soft food diet, walking with his walker, toileting, grooming, dressing, bathing, medications, scheduling/transporting to and from his doctors’ appointments. Staff stated they called 911 and sent R1 to the hospital every time they observed a change in R1’s condition. They stated they timely notified his POA, PCP and Home Health Agency (HHA) of his health condition. Review of R1’s HHA records showed he also started receiving home health services on 10/20/2023 until 12/19/2023 due to sepsis with pneumonia and acute respiratory failure. During this time, HHA nurse assessed R1’s skin condition and observed his skin intact with no open areas. Review of HHA notes dated 12/19/2023 showed R1 was assessed with no pressure ulcers on his body and that R1 was not using any pressure relieving devices while in care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff neglected resident resulting in multiple hospitalizations is unsubstantiated.

Continued on next page, LIC 9099-C pg 5
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 15-AS-20240206140145
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: 07/01/2025
NARRATIVE
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Allegation: Staff overmedicated resident in care
Investigation Finding: Unsubstantiated
During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s centrally stored medication logs and medication administration records dated 04/01/2023 until 12/30/2023 showed staff administered R1’s prescribed medications as ordered by his primary care physician. Staff denied overmedicating R1. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff overmedicated resident in care is unsubstantiated.

Allegation: Staff did not monitor resident’s change of health conditions
Investigation Finding: Unsubstantiated
During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2, S3) & R1’s responsible party (POA) and reviewed resident (R1) documents. Staff stated they monitored resident’s change in condition and timely notified his POA, PCP and HHA of his health condition and hospitalizations on 04/08/2023, 04/13/2023. 04/23/2023, 09/1720/23, 12/20/2023 and 12/30/2023. Review of R1’s home health records showed he also started receiving home health services on 10/20/2023 until 12/19/2023 due to sepsis with pneumonia and acute respiratory failure. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not monitor resident’s change in condition is unsubstantiated.

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

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 15-AS-20240206140145
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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2025
Section Cited
HSC
1569.269(a)(10)
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Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . .
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Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in developing multiple pressure injuries while in care. Additional civil penalty related to serious bodily injury is pending review.
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This requirement was not met as evidenced by resident (R1) not being rotated resulting in developing multiple pressure injuries which posed an immediate health and safety risk to resident in care.
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A non-compliance conference with CCLD will be scheduled at a later time
Type B
07/01/2025
Section Cited
CCR
87468.2(a)(5)
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To be served food of the quality and quantity necessary to meet their nutritional needs.
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A non-compliance conference with CCLD will be scheduled at a later time
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This requirement was not met as evidenced by staff did not ensure resident is being fed resulting in malnutrition which posed a potential health & safety risk to residents 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 15-AS-20240206140145
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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2025
Section Cited
CCR
87211(a)(1)
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A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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A non-compliance conference with CCLD will be scheduled at a later time
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This requirement was not met as evidenced by staff did not provide responsible party incident reports as requested which posed a potential health & safety risk to residents in care.
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Type B
07/01/2025
Section Cited
CCR
87411(d)(3)
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Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents
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A non-compliance conference with CCLD will be scheduled at a later time
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This requirement was not met as evidenced by staff did not provide adequate care and supervision resulting in resident sustaining an injury which posed a potential health & safety risk to residents 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9