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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200923
Report Date: 09/20/2024
Date Signed: 09/20/2024 05:03:44 PM


Document Has Been Signed on 09/20/2024 05:03 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:ELLE'S HOMEFACILITY NUMBER:
019200923
ADMINISTRATOR:ROCERO, MARIA CARMELAFACILITY TYPE:
740
ADDRESS:2420 COLUMBINE COURTTELEPHONE:
(510) 470-3681
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 4DATE:
09/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Maria Carmela 'Marla' Rocero/Administrator TIME COMPLETED:
05:10 PM
NARRATIVE
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While conducting investigation of a complaint (Control # 15-AS-20240918135606) and upon review of documents and interviews, Licensing Program Analyst (LPA) Delmundo learned that resident (R1) passed away on August 23, 2024, but the facility did not submit Death Report. Administrator (ADM) Maria Carmela 'Marla' Rocero confirmed that she has not submitted the Death Report.

Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. 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 with the ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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Document Has Been Signed on 09/20/2024 05:03 PM - It Cannot Be Edited

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: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements
(a) ...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events .....(A) Death of any resident from any cause regardless of where the death occurred
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Administrator to submit Death Report and ensure in the future, report will be submitted in timely manner. Proof to be submitted by 10/04/24.
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... including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
-This requirement is not met as evidenced by:
-Based on interview, the licensee did not comply with the section above in not submitting Death Report,
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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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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