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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201269
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:33:57 PM

Document Has Been Signed on 06/20/2024 03:33 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HOME SWEET ELSIEFACILITY NUMBER:
079201269
ADMINISTRATOR/
DIRECTOR:		SORIANO, CHRISTINEFACILITY TYPE:
740
ADDRESS:280 ELSIE DRTELEPHONE:
(510) 507-2679
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Caregiver, Emilia EstoniloTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 6/20/2024 at 11:45 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Emilia Estonilo and explained the purpose of the visit. Backup Administrator, Aljolyn Martinez arrived at 1:03pm. The facility’s fire clearance was approved for 6 non-ambulatory.

LPA toured facility with Backup Administrator, Aljolyn Martinez including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. 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 bathrooms was measured between 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. LPA observed centrally stored medication and sharps secured using a baby proof strap lock. LPA advised administrator it needs to be switched to a secured lock that requires a device, code, or key to open it.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 4/18/2024. Emergency Disaster Plan was last posted on 6/20/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 3/10/2024.

At 11:50am, LPA reviewed 6 residents records. At 12:20pm, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.

Report continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HOME SWEET ELSIE
FACILITY NUMBER: 079201269
VISIT DATE: 06/20/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • While in the first bathroom LPA observed that no paper towels were available to dry hands and the only available item was a shared hand towel.
  • LPA observed medications in cup unlocked in R3's room in the bedside drawer. R3 has dementia.
  • LPA observed rooms built in the garage for caregivers that are not cleared on the facility sketch and no permit was obtained prior.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/01/2024:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
Updated facility sketch


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2024 03:33 PM - It Cannot Be Edited


Created By: Alona Gomez On 06/20/2024 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HOME SWEET ELSIE
FACILITY NUMBER: 079201269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in R3 having perscription medications in night stand drawer which poses an immediate health, and safety risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator removed medications.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/20/2024 03:33 PM - It Cannot Be Edited


Created By: Alona Gomez On 06/20/2024 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HOME SWEET ELSIE
FACILITY NUMBER: 079201269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having built 2 bedrooms for staff in the garage without a permit and proper inspection which poses a potential safety risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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By POC Administrator agrees to get an inspection and submit a new facility sketch to CCLD
Type B
Section Cited
CCR
87307(a)(3)(C)
(a) Living accommodations and grounds shall be related to the facility's function...(3) Equipment and supplies necessary for personal care ...(C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths.... The use of common wash cloths and towels shall be prohibited.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a common use towel for residents to dry hands in bathroom which poses a potential health and safety risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator removed hand towel and added paper towels to the bathroom
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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