Elim Place

Type of visit: Case Management - Annual Continuation

On 6/10/2026 Licensing Program Analyst (LPA) K.Kaur arrived unannounced for an annual inspection continuation visit. LPA introduced self, explained reason for visit and was permitted entry into the facility by staff. LPA continued the annual with Administrator Maria Ceballos and Administrator Assistant Christina Gomez. LPA reviewed staff files, Staff training requirements and continued the medication audit from 06/08/2026. During inspection Ombudsman arrived regarding a SOC 341 follow-up. LPA reviewed SOC 341 and residents discharge papers and medication follow up requirements. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A $250 civil penalty is being assessed for repeat violation. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jun 10, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 6/8/2026 Licensing Program Analyst (LPA) K.Kaur arrived unannounced for an annual inspection visit. LPA introduced self, explained reason for visit and was permitted entry into the facility by staff. LPA toured the facility with the Administrator Maria Ceballos. All pathways, entrances and exits were clear from obstruction. LPA toured locked housekeeping room, and laundry room. LPA observed facility common areas were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Residents observed in common areas and in rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. Cleaning supplies and chemicals are kept locked in the maintenance room. Fire extinguishers were serviced on 5/8/2026. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Due to time constraints, inspection will be continued at a later date. No deficiencies cited during inspection.the state’s words, verbatim · CDSS document, Jun 8, 2026

The state marks this report as 10 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Due to lack of supervision, resident hit another resident

On 4/06/2026, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct a subsequent complaint inspection. LPA met with Administrator Maria Ceballos and announced the purpose of the visit. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Based on observations, interviews conducted and records reviewed, due to lack of supervision, resident hit another resident. Incident happened during dinner when caregivers were busy getting meals from kitchen and assisting residents with feeding. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. An exit interview was conducted with Administrator. A copy of this report, including appeal rights was provided to Administrator, whose signature on this form confirms receipt of this document. Substantiatedthe state’s words, verbatim · CDSS document, Apr 6, 2026 · control 24-AS-20260206133817

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 7, 2026

87464(f)(1) Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on record review and interviews due to lack of supervision facility failed to prevent resident being hit by another residentthe state’s words, verbatim · CDSS document, Apr 6, 2026

Plan of correction: Administrator agrees to develop a plan for preventative measures and complete staff training and submit records when completed.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst LPA K.Kaur conducted Case Management visit and was allowed entry by staff. LPA met with Administrator/ Executive Director Maria Ceballos. LPA discussed the purpose of the visit. Case Management Visit is regarding an incident report received in the Regional Office on 02/06/2026. The incident occurred on 01/31/26, during which R1 was given a double dosage of the same medication. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator including discussing the plan of corrections. Report signed on-site. A copy of this report and appeal rights were provided to Administrator, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Feb 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 13, 2026

87465(a)(4) (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, R1 was given multiple doses of the same medication, which poses an immediate Health & Safety risk to the residents.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Administrator conducted medication training on 2/9/26 and provided documentation during visit.

Type of visit: Case Management - Deficiencies

11/4/25, Licensing Program Analyst (LPA) J. Leffall conducted a case management – deficiency visit regarding an incident report received in the Regional Office on 10/14/25. The incident occurred on 10/6/25, during which R1 was given the wrong dose of morphine. The medication error was found during a review conducted by the hospice nurse. Citation for failing to administer medications as prescribed for R1 is on the attached 809-D. Exit interview was conducted. A copy of this report with appeal rights were provided to A1, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 5, 2025

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on records reviewed and interviews conducted, R1 was given the wrong dose of morphine, which poses an immediate Health & Safety risk to the residents.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: On 10/17/25 Staff completed medication training and submitted completion documents to CCLD by POC due date.

Allegation investigated: Facility did not take appropriate measures to safeguard resident's cash resources.

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.”) Substantiatedthe state’s words, verbatim · CDSS document, Aug 18, 2025 · control 24-AS-20250813164833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(a) · Plan of correction due date: Aug 25, 2025

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.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Per Administrator, facility will reimburse the $200 that is missing by the POC date.

Type of visit: Prelicensing

On 05/19/25, Licensing Program Analyst (LPA) M. Yang arrived announced to conduct a follow-up of the Pre-licensing inspection from visit on 04/25/25. LPA introduced self, stated the purpose of the visit and met with Licensee Elsa Nguyen and Administrator Maria Ceballos. 1. Facility has fire clearance for 44 non ambulatory, 15 maybe bedridden with total capacity of 44. Fire clearance granted for non ambulatory/ bedridden for delay egress. 2. Facility was toured with Licensee. Bathrooms hot water temperature tested at 105.9 in bathroom 1, 106.5 in bathroom 2, 108.3 in bathroom 3, 106.3 in bathroom 4, and 106.1 bathroom. 5. 3. First Aid kit was observed with all required items. Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. A copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Prelicensing

On 04/17/25, Licensing Program Analyst (LPA) M. Yang conducted a Pre-licensing and Component III inspection for Change of Ownership. Upon arrival LPA delay egress door. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Elsa Nguyen, Administrator Maria Ceballos, and Administrator Assistant Christina Gomez. All 26 residents were present during inspection. Fire clearance was granted for 44 non-Ambulatory for total of 44 capacity. Delayed egress doors observed. A sample of resident files were reviewed to have Admission Agreements, Physician Reports, and Pre-Appraisal. A sample of staff files were reviewed to have a criminal record clearance, fingerprinted clearance, and good health screening. Chemicals observed stored and locked in locked housekeeping closet. Facility dryer observed operating during inspection. Fire extinguisher observed throughout the facility with serviced date 03/11/25 and 03/06/25. LPA observed an extra supply of bed linens and personal hygiene products. All resident bedrooms were observed to have required furnishings and lighting. All bathrooms were toured. Bathrooms are observed with securely fastened grab bars and non-skid mat. Hot waters were tested at 118 degrees F in bathroom 1, 123 degrees F in bathroom 2, 85.3 degrees F in bathroom 3, 88.3 degrees F in bathroom 4, and 71.7 degrees F in bathroom 5. Courtyard was observed free of debris and adequate outdoor seatings observed available for residents.Medications observed locked in medication cart in the medication room. First aid kit was observed and contained all required items. Carbon monoxide and smoke detector tested operational during visit. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. Temperatures maintain at 38 degrees F in refrigerator 1 and -11 degrees F in freezer. First Aid kit observed with gauze, bandages, a roller, and trauma pad. The following observed will need to be brought into compliance: 1. Fire clearance for delay egress 2. All bathroom’s temperature to be range between 105 and 120 degrees F. 3. First Aid kit with required items: First aid manual approved by the American Red Cross, the American Medical Association, Sterile first aid dressings, sterile first aid dressing, bandages, scissors, tweezers and thermometers. A follow up inspection will be scheduled once all above items are in compliance. Exit interview conducted. A copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Mar 14, 2025