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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201101
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:03:14 PM

Document Has Been Signed on 04/13/2023 02:03 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: 4DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria Baez, Direct Support ProfessionalTIME COMPLETED:
02:15 PM
NARRATIVE
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On 4/13/2023 Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced case management visit regarding an incident that was reported to CCLD on 4/11/2023. LPA met with Maria Baez, Direct Support Professional (DSP) and explained the purpose of the visit. Administrator, Rene Rodriguez, arrived at 12:54PM.

Upon arrival Client 2 (C2) opened the front door and an alarm rang. LPAs stood outside and called out for the staff. Staff S2 came out of bedroom with Client 3 (C3). Staff 2 (S2) was not able to communicate with LPAs being that S2 did not speak English. LPAs asked Staff 3 (S3) did he speak Spanish and he replied "no".

LPA explained to Staff 1 (S1) the reason for the visit when he arrived. LPA obtained and reviewed the following documents: admission agreement and Medication Administration Record (MAR). S1 will email the clients’ roster and staff roster.

LPA reviewed SIR (special incident report) submitted on 4/11/2023, which stated Client 1 (C1) only had six (6) pills left on 4/3/2023. The prescription requires C1 to take two (2) tablets per day. S1 informed the pharmacy that C1 was running low, but the refill needed to be authorized by the doctor. The doctor approved the refill on 4/6/2023, but the pharmacy and surrounding pharmacies were out of stock until 4/10/2023. Administrator and staff observed C1 for any changes of condition, per Administrator there was no changes to C1’s condition.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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: ELIAS PLACE
FACILITY NUMBER: 079201101
VISIT DATE: 04/13/2023
NARRATIVE
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Continued on LIC809.

LPA interviewed S1 and he admitted that R1 missed medication from 4/6/2023 to 4/09/2023 due to medication not being refilled on time. The medication was picked up on 4/10/2023. LPA reviewed MAR which indicated the days that C1 missed the medication.

LPAs also observed the following deficiency during visit:

-At 12:45PM, LPA observed S2 was not able to communicate with LPAs and was the only staff available.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct this deficiency and/or 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/13/2023 02:03 PM - It Cannot Be Edited


Created By: Laura Hall On 04/13/2023 at 01:24 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: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not as evidence by:
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Administrator will conduct in-service training for all staff regarding the regulation that was cited and submit a copy of in-service training including all staff signatures to CCLD by POC date.
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Based on LPAs observations the Licensee did not comply with the section cited above in having prescription refilled in advance, which poses a potential health and safety risk to persons in care.
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Type B
04/20/2023
Section Cited
CCR80065(f)(3)

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80065 Personnel Requirements (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
(3) Provision of client care and supervision, including communication.
This requirement was not met as evidence by
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Administrator agreed to review regulation 80065 and submit a self-certification that the regulation has been reviewed and facility will abide by the regulation going forward. Self-certification shall be submitted to CCLD by POC date.
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Based on LPAs observations the Licensee did not comply with the section cited above in having a staff present that is able to communicate with other clients and/or persons, 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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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