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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200923
Report Date: 09/20/2024
Date Signed: 09/20/2024 05:01:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240918135606
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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maria Carmela 'Marla' Rocero/Administrator TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility not responding to resident's (R1) responsible person's call.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Administrator (ADM) Maria Carmela 'Marla' Rocero, and informed the reason for visit.

Reporting party (RP) indicated that R1 passed away on August 23, 2024; however, rent for September 2024 was paid in advance by RP. RP stated they reached out to the facility several times regarding refund and the facility is uncooperative.

LPA obtained copies of documents including but not limited to conservatorship papers. LPA intervviewed staff (S1) and ADM. S1 stated she received calls from RP. ADM stated S1 relayed to her about RP's call; however, due to the event in her family, she did not and has not responded to RP as of this date, 9/20/24.

.....continued on 9099C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20240918135606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/20/2024
NARRATIVE
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Based on information obtained, the allegation is closed as substantiated. A finding that a complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240918135606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities
(a) .......(9) To have communications to the licensee from their representatives answered promptly and appropriately.

-This requirement is not met as evidenced by:
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Administrator stated she'll communicate/respond to RP. Proof to be submitted by 10/04/24.
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-Based on records review and interviews, the licensee did not comply with the section above in not responding to R1's responsible person.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240918135606

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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maria Carmela 'Marla' Rocero/Administrator TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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2
3
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Staff did not issue responsible party a refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Administrator (ADM) Maria Carmela 'Marla' Rocero, and informed the reason for visit.

Reporting party (RP) indicated that R1 passed away on August 23, 2024; however, rent for September 2024 was paid in advance, and reached out to the facility for the refund.

LPA reviewed the documents obtained from RP and from the facility. LPA interviewed the staff (S1 and ADM) and R1's family member (FM1). FM1 confirmed RP is the conservator and responsible for financial and FM1 is the conservator for medical.

......continued on 9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240918135606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/20/2024
NARRATIVE
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LPA conducted inspection and observed the personal properties of resident (R1) are still in the facility.

Based on information obtained and due R1's personal properties still at the facility, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5