Community Care Licensing

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having water temp at 133.4F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will adjust water temp and send photo to CCL by POC Due Date showing water temp

Type A

Section Cited

CCR

87303(e)(3)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having water temp 133.4 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will adjust water temp and send photo to CCL by POC Due Date showing water temp 105-120F

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having scissors, viatmins, cleaning solutions inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator removed and locked scissors, vitamins, cleaning solutions during visit. Deficiency cleared during visit.

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by not having knives inaccessible to residents which poses an immediate health, safety risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator removed knives and locked in toolbox with a new pad lock during visit. Deficiency cleared during visit.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having vitamins unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator removed the vitamins and locked up during visit. Deficiency cleared.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having TB and Health Screenings for all staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator to schedule TB tests and Health Screening for all staff and send copies to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87465(f)(1)

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having name, addresses, telephone numbers of resident's physicians and dentists on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update records and submit a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87208(d)

(d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having Bedridden for R2 and R3 included in their plan which can pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update Plan of Operation for Bedridden. Administrator will send updated record for R3 in Shared Bedroom#2.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by not having shower chair, microwave in outside back side yard accessible to residents in care which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will remove items and send a picture to CCLD by POC Due Date

Type B

Section Cited

CCR

87303(e)(5)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having Non-skid mats in Shared Bathroom#2 which posesa pote ntial health and safety risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will place non-skid mats in resident's bathroom and send a photo to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having complete staff records maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update all staff personnel records and send a copy of the names of all staff that records are complete along with a photo of all staff records to CCLD by POC Due Date

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having each resident's records available, e.g., R3 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update resident's records and send a copy and/or pictures of R3's records

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87506(b)(9)

(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having resident's records with physician's telephone numbers which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update and send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87506(b)(11)

(b) Each resident's record shall contain at least the following information: (11) The documentation required by Section 87611(a) for residents with an allowable health condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having health condition for R3 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update and send a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having the appraisals completed for residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete appraisals and pre-appraisals and send copies to CCLD by POC Due date

Type B

Section Cited

CCR

87506(b)(17)(A)

(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having Pre-Admission Appraisal which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete and send a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87506(b)(17)(B)

(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (B) Section 87459, Functional Capabilities; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having Functional Capabilities on file for residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete and submit a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87506(b)(17)(C)

(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (C) Section 87461, Mental Condition; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having Mental Conditions for residents in care which posesa potent ial health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete and submit a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87506(b)(17)(E)

(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (E) Section 87463, Reappraisals; and This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Reappraisals for residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete reappraisals and send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having pre-admission appraisal for residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy of pre-admission appraisal to CCLD by POC Due Date and make sure that such appraisals are completed prior to admission for future residents

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87457(c)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having on file an appraisal of individual service needs which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87457(c)(1)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a Pre-Admission Appraisal for residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy of pre-admission appraisal to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having signed Physicians Report for all residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87458(b)

(b) The medical assessment shall include, but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having medical assessments for residents, R3 in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having full diagnosis information on residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update and send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87458(b)(5)

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having medical assessments of all residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send copies to CCLD by POc Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by having reappraisals for residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will do re-appraisals and send copies to CCLD by POC Due Date

Type B

Section Cited

CCR

87467(a)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having meetings with residents and their reps which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will do re-appraisals and send copies to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by having meeting scheduled with residents and their reps which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will submit copies of updated meeting notes to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87507(e)(2)

(2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a copy of Admission Agreement which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete and send a photo to CCLD by POC Due Date

Type B

Section Cited

CCR

87508(b)

(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having resident registry roster completed and on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete and send a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87508(a)(1)

(1) The resident's name and ambulatory status as specified in Section 87506(b)(1) and (b)(10). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having R3's Medical Assessment on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete a Medical Assessment and send to CCLD by POC Due Date

Type B

Section Cited

CCR

87508(a)(2)

(2) Information on the resident's attending physician as specified in Section 87506(b)(7). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having R3's Medical Assessment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will get Physician's Report for R3

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87508(a)(3)

(3) Information on the resident's responsible person as specified in Section 87506(b)(6). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having R3's information on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will get R3's information and send copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87508(c)(1)

(1) The register shall be treated as confidential information pursuant to Section 87506(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having registry information of all residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will get ALL Resident's information and send copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

HSC

1569.695(a)(1)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by not having such plans available which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete plan and send a copy to CCLD by POC Due Date

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having fire drills completed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will conduct a fire drill with staff and have all staff sign-off that they participated and send a copy of fire drill to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

HSC

1569.695(d)

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not reviewing plans annually. R2 has been at facility over a year and no review in file which posesa pote ntial health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update R2's file and send a copy to CCLD by Due Date

Type B

Section Cited

HSC

1569.695(e)(1)

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in noy having resident roster's completed which posesa potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete resident's roster and send a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

HSC

1569.695(e)(2)

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having Appraisal Needs and Services Plans for residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete Appraisal Needs and Sevices for R1, R2 and R3 and send copies to CCLD by POC Due Date

Type B

Section Cited

CCR

87632(d)(2)

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by notifying CCL of R2's hospice care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will submit Initiation of Hospice Services for R2 to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87633(b)

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having hospice care plan for R2 in their file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy of hospice care plan to CCLD by POC Due Date

Type B

Section Cited

CCR

87633(b)(1)

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (1) The name, office address, business telephone number, and 24-hour emergency telephone number of the hospice agency and the resident's physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a complete hospice care plan for R2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will submit a copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87633(b)(4)

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a hospice care plan for R2's file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87633(b)(4)(A)

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. (A) The plan shall specify all procedures to be implemented by the licensee regarding the storage and handling of medications or other substances, and the maintenance and use of medical supplies, equipment, or appliances. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a complete hospice care plan for R2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will submit hospice care plan to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023

Type B

Section Cited

CCR

87633(h)(1)

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (1) A written request for acceptance or admittance to or retention in the facility while receiving hospice services, along with any advance directive and/or request regarding resuscitative measures form executed by the resident or (in certain instances) the resident's Health Care Surrogate Decision Maker. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having in the resident's files an advanced directive which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update and send a copy to CCLD by POC Due Date

Type B

Section Cited

CCR

87633(h)(5)

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having R2's acknowledgement to receive hospi ce care and R3's agreement to shared living space which posesa potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Administrator will update the records and file documents. Administrator will send a signed copy to CCLD by POC Due Date

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023

Document Has Been Signed on 06/27/2023 07:19 PM - It Cannot Be Edited

FACILITY NAME: ELISABETH CARE HOME	FACILITY NUMBER: 079200380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2023