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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209543
Report Date: 08/18/2025
Date Signed: 08/19/2025 08:40:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2025 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250813164833
FACILITY NAME:ELIM PLACEFACILITY NUMBER:
107209543
ADMINISTRATOR:CEBALLOS, MARIAFACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(650) 776-2280
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:44CENSUS: 26DATE:
08/18/2025
UNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Maria CeballosTIME COMPLETED:
03:17 PM
ALLEGATION(S):
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Facility did not take appropriate measures to safeguard resident's cash resources.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Xiong conducted a complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The evidence from the investigation indicated that $200 was missing from resident #1's P&I money. It's uncertain on how it happened, however the facility will reimburse resident #1 for the missing amount. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20250813164833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ELIM PLACE
FACILITY NUMBER: 107209543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2025
Section Cited
CCR
87217(a)
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87217 (a)
Safeguards for Resident Cash, Personal Property, and Valuables : A licensee shall not be required to handle residents' cash resources. However, if a resident incapable of handling his own cash resources, as documented by the initial or subsequent appraisal, is accepted for care, his cash resource shall be safeguarded in accordance with the regulations in this section.
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Per Administrator, facility will reimburse the $200 that is missing by the POC date.
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2