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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200923
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:27:33 AM

Document Has Been Signed on 12/17/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELLE'S HOMEFACILITY NUMBER:
019200923
ADMINISTRATOR/
DIRECTOR:		ROCERO, MARIA CARMELAFACILITY TYPE:
740
ADDRESS:2420 COLUMBINE COURTTELEPHONE:
(510) 470-3681
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:07 AM
MET WITH:Maria Carmela Rocero, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On 12/17/2024 at 10:07 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Maria Carmela Rocero and explained the purpose of the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/24/2024. Emergency Disaster Plan was last posted on 11/08/2020. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/07/2024.

At 10:45 AM, LPA reviewed 4 residents records and 3 staff records; all were complete. At 11:15 AM, LPA also reviewed residents medications.

The following documents were reviewed and requested during the visit: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, renewed Liability Insurance and Current Administrator’s Certificate.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Ardalan GharachorlooTELEPHONE: (510) 286-4201
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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