<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200841
Report Date: 04/22/2022
Date Signed: 05/03/2022 10:35:27 AM

Document Has Been Signed on 05/03/2022 10:35 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:ELENA'S CARE HOME LLCFACILITY NUMBER:
019200841
ADMINISTRATOR:TABING, BONNIE JEANFACILITY TYPE:
735
ADDRESS:22349 WESTERN BLVDTELEPHONE:
(510) 690-1710
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bonnie Jean Tabing/AdministratorTIME COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Bonnie Jean Tabing, administrator, and informed the purpose of visit. LPA also met with other staff, Caridad Escarez and Wilena May Bautista.

Facility has LIC808 Mitigation Plan on file. All staff were fit tested for N95 respirators on August 2021.

LPA toured the facility inside out with Bonnie Jean Tabing. LPA inspected the living room, dining area, kitchen, bathrooms, laundry room, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch thermometer. Surgical masks and disposable gloves are readily available at the screening station. Visitor's temperature and symptom checks are done at entry for visitors. Residents and staff are screened for COVID-19 symptoms and temperature is checked daily. Facility keeps record of proof of vaccination of visitors and antigen test kits are readily available. COVID-19 signages were observed posted all throughout the facility. Supplies of PPEs were checked.

Hot water temperature at the common bathroom was tested and measured at 107.9 degrees Fahrenheit. Fire extinguisher checked and observed fully charge with tag showed serviced January 4, 2022. First aid kit was observed complete with manual.


......continued next page
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELENA'S CARE HOME LLC
FACILITY NUMBER: 019200841
VISIT DATE: 04/22/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At 12:00 noon, LPA observed the trash bin in the bathroom with no lid.

At around 12:12 pm, LPA observed pavement in the backyard uneven.

On this day, LPA obtained the following updated documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. Proof of Surety bond coverage

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/03/2022 10:35 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/22/2022 at 01:35 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 LLC
FACILITY NUMBER: 019200841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed uneven pavement in the backyard which poses potential safety risks to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
1
2
3
4
Adminstrator stated she'll have the yard even out with sand and submit picture by 5/06/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5