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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200869
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:02:49 PM

Document Has Been Signed on 07/06/2023 04:02 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELIZABETH CARE HOMES 2FACILITY NUMBER:
079200869
ADMINISTRATOR:CARMELITA PAYTONFACILITY TYPE:
740
ADDRESS:1840 KERN MOUNTAIN WAYTELEPHONE:
(925) 238-0311
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Henry Sevilla, Staff
Ime Ekanem, Administrator		TIME COMPLETED:
04:50 PM
NARRATIVE
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On 07/06/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to 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 (ADM, S1).

LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station.

Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper handwashing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in med room cabinets.

Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/06/2023
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LPA observed the following deficiency during visit:
  • Fire extinguisher was last inspected on 10/20/21
  • Open trash bins with no lids in living area

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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/07/23:


 LIC500- Personnel Report
 Resident Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2023 04:02 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 07/06/2023 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELIZABETH CARE HOMES 2
FACILITY NUMBER: 079200869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(4)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with Section 87303 (a)(4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers which posed a potential health & safety risk to residents in care
POC Due Date: 07/28/2023
Plan of Correction
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By POC due date, administrator agreed to replace open trash bins and submit to CCL proof of purchase receipt of trash bins with foot operated lids.
Type B
Section Cited
CCR
87203


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with Section 87203 - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic due to expired fire extinguisher (last inspected on 10/20/2021) which posed a potential health & safety risk to residents in care
POC Due Date: 07/28/2023
Plan of Correction
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By POC due date, Administrator agreed to submit to CCL a copy of purchase receipt for new fire extinguisher. Administrator also agreed to tape copy of purchase receipt at the bottom of new fire extinguisher cylinder to show date of purchase.
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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


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