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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200570
Report Date: 05/21/2021
Date Signed: 05/21/2021 02:31:49 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:ELLURA HOME CARE SERVICESFACILITY NUMBER:
079200570
ADMINISTRATOR:RAMIN, LUCENA MFACILITY TYPE:
740
ADDRESS:4348 SATINWOOD DRIVETELEPHONE:
(925) 689-2168
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
05/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gilbert Hernandez, Caregiver
Shan Gao, Administrator		TIME COMPLETED:
02:45 PM
NARRATIVE
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On 5/21/2021 at 9:15AM, Licensing Program Analysts (LPAs) G. Luk and L. Hall arrived unannounced to conduct a case management inspection due to a change of ownership. LPAs met with caregiver, Gilbert Hernandez and administrator, Shan Gao arrived an hour later.

During Pre-licensing Inspection, LPAs observed the following deficiencies:

At 9:30AM, LPAs observed S4 was not fingerprint cleared and associated the facility. LPAs called the office to confirm S4 was not cleared. S4 started training/working at the facility yesterday, 5/20/2021.

At 9:50AM, LPAs observed R3's prescription medications were unlocked in the refrigerator. Administrator put the medication in the refrigerator located in the garage which is locked and inaccessible to residents.

At 9:50AM, LPAs observed unlocked knives under the kitchen sink. Caregiver locked the cabinet under the sink during inspection.

At 10:00AM, LPAs measured hot water temperature at 130.8 degree F. Caregiver lowered hot water temperature during inspection. LPAs re-measured hot water temperature at 109.9 degree F.

At 10:12AM, LPAs observed gardening tools (shovel, rack) and paint supplies left unlocked in the backyard and accessible to residents.

Continue on LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: ELLURA HOME CARE SERVICES
FACILITY NUMBER: 079200570
VISIT DATE: 05/21/2021
NARRATIVE
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At 10:35AM, LPAs observed S1 was not associated to the facility during inspection.

At 10:40AM, LPAs observed S1 and S4 did not have files for review during record review.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Shan Gao. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: ELLURA HOME CARE SERVICES
FACILITY NUMBER: 079200570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2021
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility... This requirement is not met as evidence
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by: Based on record review, licensee did not comply with the section cited above which poses an immediate health and safety risk to the residents in care.
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Type A
05/22/2021
Section Cited

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Maintenance and Operation. ...Hot water temperature...shall be maintained...not less than 105 degree F and not more than 120 degree F... This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above by having hot water above 130.8 degree F which poses an immediate health and safety risk to the residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: ELLURA HOME CARE SERVICES
FACILITY NUMBER: 079200570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2021
Section Cited

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible...
This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above by having unlocked medication in refrigerator which poses an immediate health and safety risk to the residents in care.
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by POC date.
Type A
05/22/2021
Section Cited

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Storage Space. Disinfectants...and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above by having unlocked knives, gardening tools and paint supplies which poses an immediate health and safety risk to the residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: ELLURA HOME CARE SERVICES
FACILITY NUMBER: 079200570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2021
Section Cited

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Personnel Records
All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidence by:
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Based on record review, licensee did not comply with the secion cited above by not having S1 and S4's records which poses a potential health and safety risk to the residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5