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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200869
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:57:38 PM

Document Has Been Signed on 08/31/2023 02:57 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:IME IKANEMFACILITY TYPE:
740
ADDRESS:1840 KERN MOUNTAIN WAYTELEPHONE:
(925) 238-0311
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 5DATE:
08/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Ime Ikanem, Administrator
Perla Agpalasin, Staff		TIME COMPLETED:
03:15 PM
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While at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio reviewed a written eviction notice issued by administrator (ADM) to resident (R1) on 08/21/23. The written eviction notice showed ADM gave R1 10 days to vacate his room at the facility effective September 1, 2023.

LPA observed ADM improperly evicted R1 by not abiding by R1’s admission agreement which state that thirty (30) days written eviction notice to the resident is required.

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
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 2
Document Has Been Signed on 08/31/2023 02:57 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 08/31/2023 at 02:31 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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87224(a)

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(a) (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required …
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By POC due date, Administrator agrees to complete and submit to CCL in-service staff retraining certifications on proper eviction procedures in compliance with Title 22 Section 87224.
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This requirement was not met as evidenced by the improper eviction of resident which posed a potential health and safety risk to resident 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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