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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201417
Report Date:
01/08/2025
Date Signed:
01/08/2025 11:37:31 AM
Document Has Been Signed on
01/08/2025 11:37 AM
- 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:
ELIM ASSISTED LIVING
FACILITY NUMBER:
079201417
ADMINISTRATOR/
DIRECTOR:
TET, SAMUEL
FACILITY TYPE:
740
ADDRESS:
3653 WREN AVENUE
TELEPHONE:
(510) 292-8610
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94519
CAPACITY:
6
CENSUS:
6
DATE:
01/08/2025
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:
Samuel Tet, Administrator
TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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LPA conducted Component III with Licensee and Administrator. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.
Exit interview conducted and a copy of this report will be provided.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/08/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/08/2025
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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