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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201101
Report Date: 12/20/2022
Date Signed: 12/20/2022 12:08:38 PM

Document Has Been Signed on 12/20/2022 12:08 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:
(925) 978-4342
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 5DATE:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Rene Rodriguez, AdministratorTIME COMPLETED:
12:20 PM
NARRATIVE
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On 12/20/2022 at 11:05AM, Licensing Program Analysts (LPA) L. Hall and L. Homes conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 12/02/2022. LPAs met with Rene Rodriguez, Administrator and explained the purpose of the visit.

Incident report for C1 was sent on 12/2/2022. Staff (S1) stated that Client 1 (C1) have been having some behaviors and staff is working with psychiatrist to help C1. S1 stated that Client 2 (C2) had two (2) respite stays three (3) times each time to see if C2 would be compatible with the facility and during the respite stay everything went well. The problem started when C2 moved in permanently. S1 stated that C1 wants the room all to himself. S1 stated the Staff has placed a curtain divider between C1 and C2 for privacy, put a lock on C1's closet and given C1 the key to try and help the situation. RCEB (Regional Center of East Bay) is trying to find C1 placement where he would have his own room. S1 stated that C2 is not afraid to stay in the room with C1.

During visit LPAs reviewed C2's file and observed missing documents. LPAs observed the file contained the admission agreement from RCEB, vaccine, and placement information.

Continued on LIC809C.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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 12/20/2022 12:08 PM - It Cannot Be Edited


Created By: Laura Hall On 12/20/2022 at 11:40 AM
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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited
CCR
80070(a)

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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:
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Administrator agreed to complete C2's file and submit a pdf document with all documents to CCLD by POC date.
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Based on LPAs observation and records review the Licensee did not comply with the section cited above in maintaining complete records for C2 which poses a potential health and safety risk to 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022


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: ELIAS PLACE
FACILITY NUMBER: 079201101
VISIT DATE: 12/20/2022
NARRATIVE
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Continued from LIC809.

An immediate civil penalty of $250.00 will be assessed on today's date for a repeat violation.

The deficiency were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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