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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200841
Report Date: 04/05/2024
Date Signed: 04/05/2024 05:04:57 PM

Document Has Been Signed on 04/05/2024 05:04 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/
DIRECTOR:		TABING, BONNIE JEANFACILITY TYPE:
735
ADDRESS:22349 WESTERN BLVDTELEPHONE:
(510) 690-1710
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Bonnie Jean Tabing/Administrator TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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At 11:40 am on this day, April 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Bonnie Jean Tabing, administrator, and informed the reason for visit. LPA also met with other staff, Wilena May Bautista and Caridad Escarez.

Administrator submitted a copy of updated Infection Control Plan which LPA received on July 7, 2023.

LPA toured the facility inside out with the administrator, LPA inspected the kitchen, dining area, living room. bedrooms, bathrooms. side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were tested, and observed functional. Facility conducts disaster drills monthly and records showed last conducted April 3, 2024. Fire extinguisher checked, observed fully charge with tag showed serviced December 19, 2023. Hot water temperature was tested and measured at 106.4 degrees Fahrenheit.

LPA reviewed 4 staff and 5 residents records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked and compared with last recorded balance.


....continued on 809
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELENA'S CARE HOME LLC
FACILITY NUMBER: 019200841
VISIT DATE: 04/05/2024
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LPA received the following updated/current 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

At 3:00 p.m., LPA observed R2's order on 1 medication on LIC602 is once daily but the medication on hand is twice daily..

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction 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: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2024 05:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/05/2024 at 04:07 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: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R2's order of 1 medication on LIC602 is 25 mg 1 tab daily (am) but the med on hand is 2x daily which poses which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Corrected.
Administrator obtained copy of doctor's order while LPA was at the facility.
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: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024


LIC809 (FAS) - (06/04)
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