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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200841
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:58:57 PM

Document Has Been Signed on 04/21/2023 03:58 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
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:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Bonnie Jean Tabing/Administrator TIME COMPLETED:
03:50 PM
NARRATIVE
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On this day, April 21, 2023, at 10:25 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Caridad Sanchez, and informed the reason for visit. LPA also met with other staff, Wilena May Bautista. LPA called, and spoke with Bonnie Jean Tabing, administrator, over the phone who authorized Caridad Sanchez to be with LPA in touring the facility. Administrator arrived at around 11:10 a.m.

LPA inspected the facility inside and out including but not limited to bedrooms, bathroom, laundry and shower room, kitchen, dining and living areas, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced December 28, 2022. Facility has carbon monoxide and smoke detector that were tested and observed functional. Hot water temperature in the common bathroom was tested and measured at 113.4 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted April 16, 2023.

LPA reviewed 5 residents and 4 staff files, and interviewed 2 residents and 2 staff. Medications were checked and compared with records. Residents' cash resources reconciled with records.

During records review, LPA observed resident's (R2) Visit Summary dated 4/07/23 included 3 medications on the medication list but these medications were not on facility's hand. According to the administrator, the medications were not received and administered. LIC622 Centrally Stored Medication And Destruction Record, and Medication Administration Record (MAR) confirmed administrator's statement.



......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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 04/21/2023 03:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/21/2023 at 02:40 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: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for not having the 3 medicatons administered to resident (R2) which poses immediate health risks to person in care.
POC Due Date: 04/22/2023
Plan of Correction
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Corrected.
On this same day, 4/22/23, administrator called the resident's primary care physician (pcp), and have one of the staff go to the pcp's office to check if the medications are still needed. Copy of discontinued order provided while LPA was at the facilty.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELENA'S CARE HOME LLC
FACILITY NUMBER: 019200841
VISIT DATE: 04/21/2023
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LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D.

Deficiency and plan and proof of corrections were discussed with the administrator.

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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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