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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201101
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:55:26 PM

Document Has Been Signed on 03/27/2024 12:55 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:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rene Rodriguez, AdministratorTIME COMPLETED:
01:00 PM
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On 3/27/2024 at 12:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 3/20/2024. LPA met with Rene Rodriguez, Administrator, and explained the purpose of the visit.

Administrator submitted an incident report for an AWOL that occurred on 3/17/2024. S1 stated C1 left out of the emergency exit on side of facility. A missing person's report was filed with Antioch Police Department. S1 stated on 3/19/2024 a staff member, while off duty, observed C1 at the Pittsburg mall and called Administrator. S1 then went and found C1 and call the Pittsburg Police Department. S1 stated he tried to get C1 to return. S1 bought C1 food and drink. S1 stated C1 said he would return later. The Pittsburg Police officer stated C1 was not aggressive and is an adult so there was nothing they could do. C1 has not returned to the facility as of today's date.

LPA obtained the following documents of C1: physician's report, appraisal needs and services plan, admission agreement, identification and emergency contact, individual program plan (IPP), any documents regarding the program C1 is on at this time and dangerous propensities.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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