019200923-12-9-2021-15-AS-ADEO-C9JUCN-20211209142814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200923
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:30:18 PM

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:	ELLE'S HOME		FACILITY NUMBER:	019200923
ADMINISTRATOR:	ROCERO, MARIA CARMELA		FACILITY TYPE:	740
ADDRESS:	2420 COLUMBINE COURT		TELEPHONE:	(510) 470-3681
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 5	DATE:	12/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Carmela 'Marla' Rocero/Administrator		TIME COMPLETED:	02:45 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 Maria Carmela 'Marla' Rocero, administrator, and informed the purpose of visit. LPA also met with other staff, Rebecca Go and Noel Rocero. Facility has an approved LIC808 COVID-19 Mitigation Plan. LPA inspected the facility inside and out. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Medications are centrally stored in the a locked cabinet. Centrally stored PPEs inspected. There were at least 7 days of nonperishable and 2 days of perishable food supplies. Fire extinguisher was observed fully charge and tag showed serviced December 3, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual. LPA observed the following: 1. Storage for cleaning supplies in the backyard without lock. LPA observed bleach, floor cleaner, carpet spot cleaner inside the storage. 2. Gardening tools such as rake and shears in the side yard. 3. Worn out wheelchairs, broken pipes, floor cleaner, 2 pails of paint in the backyard. 4. Dowel at the bottom of sliding door in the residents' shared bedroom. .....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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: ELLE'S HOME	FACILITY NUMBER: 019200923
	VISIT DATE: 12/09/2021

NARRATIVE

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4. No visitor's poster and COVID-19 signages at the entrance door.
5. No COVID-19 signages inside the facility except in the common bathroom.
6. Trash bins in the bathrooms without lids.
6. Disposable gowns, N95 respirators, surgical masks not sufficient for 30 days for 3 staff.

LPA verified and Marla Rocero stated the following:
1. Staff are not fit tested for N95 respirator.
2. Residents' temperature are not routinely checked.

LPA requested for copies of the following updated documents to be submitted by December 23, 2021:
1. LIC500 Personnel Report
2. LIC308 Designation of Facility Responsibility
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance coverage

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Marla Rocero,

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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: ELLE'S HOME	FACILITY NUMBER: 019200923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants 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 obseved the following which pose immediate safety risks to persons in care: cleaning supplies storage without lock; pails of paint and floor cleaner in the backyard; gardening tools in the side yard
	POC Due Date: 12/09/2021
	Plan of Correction
1 2 3 4	Staff installed lock in the storage and lock the gardening tools, pails of paint and cleaning and gardening supplies while LPA is still at the faciliy. Administrator to in-service the staff and submit proof by 12/10/2021.

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	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: ELLE'S HOME	FACILITY NUMBER: 019200923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 worn out wheelchairs and broken pipes in the backyard which pose a potential safety and personal rights risks to persons in care.
	POC Due Date: 12/23/2021
	Plan of Correction
1 2 3 4	Administrator to have the yard cleaned and submit pictures by December 23, 2021.

Type B

Section Cited

HSC

1569.269

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. 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 dowel at the bottom of the sliding door in residents' bedroom that prevents the door from opening which poses a potential safety and personal rights risks to persons in care.
	POC Due Date: 12/23/2021
	Plan of Correction
1 2 3 4	Administrator removed the dowel immediately. In addition, administrator to do in-service training and ensure staff does not put back the dowel. Proof to be submitted by December 23, 2021.

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	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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