<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201101
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:52:30 PM

Document Has Been Signed on 07/14/2022 01:52 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:ELIAS PLACEFACILITY NUMBER:
079201101
ADMINISTRATOR:RODRIGUEZ, RENEFACILITY TYPE:
735
ADDRESS:2355 GLENDALE CIRTELEPHONE:
(904) 859-1773
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
07/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Rene Rodriguez, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/14/2022 at 1:05PM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Rene Rodriguez, Administrator.

While LPA L. Hall was conducting a complaint investigation (15-AS-20220708121700) on 7/14/2022. Upon arrival LPA was greeted by S1 and S2, LPA reviewed facility roster from guardian and observed S2 was not associated to facility. S1 stated that S2 recently came from the other facility to work here due to staffing. LPA also observed S3 was not associated to the facility.

During record review while conducting the complaint investigation LPA observed C1, C2, C3, and C4 files were incomplete. C1, C2, and C3 files only contained the admission agreement. C4's file had most required documents but there was not any signatures.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the 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: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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 07/14/2022 01:52 PM - It Cannot Be Edited


Created By: Laura Hall On 07/14/2022 at 01:18 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: ELIAS PLACE
FACILITY NUMBER: 079201101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
80019(e)(1)

1
2
3
4
5
6
7
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to submit LIC9182 and a copy of S2 and S3's identification to CCLD by POC date. Administrator submitted LIC9182 and idenfication to LPA during visit. Deficiency cleared during visit.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in having S2, and S3 associated to facility which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
07/21/2022
Section Cited
CCR80070(a)

1
2
3
4
5
6
7
80070 Client Records (a) The licensee shall ensure that a ...complete, and current record is maintained in the facility for each client. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to review Regulation 80070 Client records and submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. Self-certification will be submitted by the POC date.
8
9
10
11
12
13
14
Based on LPAs observation and records review the Licensee did not comply with the section cited above in maintaining complete records for C1, C2, C4 and C4 which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2