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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600388
Report Date: 11/25/2024
Date Signed: 11/25/2024 05:00:41 PM

Document Has Been Signed on 11/25/2024 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELENA'S CARE HOMEFACILITY NUMBER:
015600388
ADMINISTRATOR/
DIRECTOR:		ALETA ALABASTROFACILITY TYPE:
735
ADDRESS:40320 FREMONT BOULEVARDTELEPHONE:
(510) 651-0232
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 5DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Alona Alfonso, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 11/25/2024 at 1:15 PM, Licensing Program Analyst (LPA) Patricia Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Alona Alfonso, and explained the purpose of the visit. Administrator certificate is current and administrator number is 6068534735. Administrator certificate expires on 04/08/2026. The facility’s fire clearance was approved for all six (6) ambulatory only.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four total bedrooms which three bedrooms are occupied by the clients and one bedroom is occupied by staff. There are no bodies of water. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111.1 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's and linen supplies was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Cabinet for knives, cleaning supplies, and centrally storage for medication were observed locked. Outdoor activity space was observed furnished with tables, chairs and shade.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/12/2024. First aid kit was observed to be complete. Emergency Disaster Drill was last posted on 11/25/2024. Fire Drill was last conducted on October 5, 2024.

At 2:10 PM, 5 of 5 clients records were reviewed. At 3:10 PM, 4 staff records were reviewed and 4 of 4 have current first aid training and 4 of 4 associated to the facility. At 4:05 PM, LPA reviewed client's P&I money with log and there was no discrepancies observed. LPA reviewed a sample of client's medications. All records were observed to be complete and up to date.

Continue to LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELENA'S CARE HOME
FACILITY NUMBER: 015600388
VISIT DATE: 11/25/2024
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/03/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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