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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201227
Report Date: 10/08/2025
Date Signed: 10/08/2025 11:05:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250709144316
FACILITY NAME:CARE 4 ONE IIFACILITY NUMBER:
079201227
ADMINISTRATOR:ELEGADO, LIZA JAYFACILITY TYPE:
740
ADDRESS:3910 BAYVIEW CIRTELEPHONE:
(925) 464-3891
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 6DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emma Baldeo, CaregiverTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff are not trained on emergency disaster protocols
Staff are not providing activities for residents
INVESTIGATION FINDINGS:
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On 10/08/2025 at 9:30AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and Andrew Christy arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Emma Baldeo, Caregiver and explained the reason for the visit. Emma contacted Administrator Liza Jay Elegado who arrived at 10:08AM.


During the investigation, LPA reviewed and obtained documents, interviewed staff members, residents and witness.

Continue on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250709144316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CARE 4 ONE II
FACILITY NUMBER: 079201227
VISIT DATE: 10/08/2025
NARRATIVE
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Continued from LIC9099


Staff are not trained on emergency disaster protocols

During investigation, LPA interviewed three (3) residents and two (2) staff members. Interviews with residents R1, R2 and R3, revealed that there haven’t been any emergency disaster drills (fire/earthquake) since admissions. Interviews with staff S1 and S2 revealed no emergency disaster drills have been conducted since 2023.


Staff are not providing activities for residents

During investigation, LPA interviewed three (3) residents and two (2) staff members. Interviews with residents R1, R2 and R3, revealed that the only activity they have participated in is with a Physical Therapist (PT) who visits one of the other residents twice a week. Interviews and record review revealed the facility isn’t providing residents with activities that develop their quality of life.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250709144316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CARE 4 ONE II
FACILITY NUMBER: 079201227
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
HSC
1531.2(7)
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1531.2(7) Emergency fire and earthquake drills shall be conducted at least once every three months, or more frequently as required by a county or city fire department or local fire prevention district. The drills shall include all facility staff and volunteers providing client care and supervision. This requirement is not met as evidenced by:
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Administrator agreed to read health and safety code1531.2(7), conduct training at least once every three months and email CCLD names of staff participants with signatures by POC date.

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Based on interviews and file review, the licensee did not comply with the section cited above by not having emergency fire and earthquake drills at least once every three months for the residents in care which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/15/2025
Section Cited
CCR
87219(a)
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(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by:
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Administrator agreed to create a planned activity calendar with activities that will develop quality of life for residents in care and email photos of monthly activities to CCLD by POC date.
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Based on interviews and record review, the licensee did not comply with the section cited above by not having planned activities that maintain and develop quality of life for the residents in care which poses a potential health, safety or personal rights 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3