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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600388
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:10:37 PM

Document Has Been Signed on 01/07/2025 03:10 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:		ALONA BARTOLO ALFONSOFACILITY TYPE:
735
ADDRESS:40320 FREMONT BOULEVARDTELEPHONE:
(510) 651-0232
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Alona Alfonso, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 01/07/2025 at 1:50 PM, Licensing Program Analysts (LPAs), Manalo and L. Fontanilla arrived unannounced to conduct a case management visit. LPAs met with Administrator, Alona Alfonso, and explained the purpose of the visit.

The case management visit was for a follow-up from an annual inspection completed on 11/25/2024. During today's visit, LPAs reviewed one client file and observed that the Physician’s Report stated the client to have dementia and is non-ambulatory. Facility fire clearance for the facility is for six (6) ambulatory client only.

C1 was given a 1:1 care from RCEB in June 2024 due to mobility issues. Administrator states that RCEB is looking for another housing placement suitable for client's needs.

At 2:30 PM, LPAs observed during record review that C1 has dementia and is non-ambulatory.

*An immediate civil penalty will be assessed on today's date for $500.00 for fire clearance*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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Document Has Been Signed on 01/07/2025 03:10 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/07/2025 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ELENA'S CARE HOME
FACILITY NUMBER: 015600388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department...

This requirement is not met as evidenced by:
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Within 24 hours, the Administrator will notify the local fire department about the non-ambulatory client and issue a 30-day eviction notice. Proof will be sent to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above by having C1 who is non-ambulatory admitted and the facility does not have a non ambulatory fire clearance which poses an immediate health and safety 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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