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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200869
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:07:54 PM

Document Has Been Signed on 02/07/2024 03:07 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: 4DATE:
02/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Henry Sevilla, CaregiverTIME COMPLETED:
03:22 PM
NARRATIVE
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On 2/7/2024 at 1:50PM, Licensing Program Analyst (LPA) G. Luk conducted an unannounced Health & Safety inspection as a result of a priority 1 complaint. LPA met with Caregiver, Henry Sevilla and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, kitchen, common areas, garage, and outdoor area. Hot water temperature was measured at 113.6 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the kitchen cabinet. Smoke and carbon monoxide detectors observed. First-aid kit was complete. Fire extinguisher was observed to be full and purchased on 7/10/2023. There are no accessible bodies of water observed.

At 2:10PM, LPA observed unlocked comet in the hallway bathroom. LPA observed cabinet under the kitchen sink was unlocked and cleaning supplies were unlocked. Kitchen knives drawer was unlocked. Staff locked up the cabinets and drawer during inspection.

At 2:20PM, LPA observed portion of the side fence has fallen down into the neighbor's yard. LPA observe the other side fence is leaning.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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Document Has Been Signed on 02/07/2024 03:07 PM - It Cannot Be Edited


Created By: Grace Luk On 02/07/2024 at 02:42 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: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2024
Section Cited
CCR
87309(a)

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Storage Space. Disinfectants, cleaning solutions...and other items which could pose a danger ...shall be stored... inaccessible to clients. This requirement is not met as evidence by:
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Staff locked up the cleaning supplies and knives during inspection.

Deficiency cleared.
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Based on observation, licensee did not comply with the section cited above by having cleaning supplies and knives accessible which poses an immediate health and safety risk to the persons in care.
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Type B
02/29/2024
Section Cited
CCR87303(a)

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by:
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Facility has agreed to create a written plan to fix the side fence that has fallen and the other side fence that is leaning. Facility will submit plan to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by having the side fence in disrepair which poses a potential health and safety risk to the persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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