019200923-12-6-2023-15-AS-ADEO-CYA4Y6-20231206183036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200923
Report Date: 12/06/2023
Date Signed: 12/06/2023 06:30:44 PM

Document Has Been Signed on 12/06/2023 06:30 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 HOME		FACILITY NUMBER:	019200923
ADMINISTRATOR:	ROCERO, MARIA CARMELA		FACILITY TYPE:	740
ADDRESS:	2420 COLUMBINE COURT		TELEPHONE:	(510) 470-3681
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 6	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Maria Carmela 'Marla' Rocero/Administrator		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 11:55 am on this day, December 6, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by Noel Rocero, staff. LPA met with Maria Carmela 'Marla' Rocero, administrator, and informed the reason for visit. LPA also met with other staff, Rebecca Go. Administrator submitted the facility's updated Infection Control Plan which LPA received on August 27, 2023. LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 105 degrees Fahrenheit. Facility conducts disaster drills quarterly, and records showed last conducted December 2, 2023. Fire extinguisher checked, and tag showed serviced December 5, 2023. LPA reviewed 3 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle residents' cash resources. .....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELLE'S HOME	FACILITY NUMBER: 019200923
	VISIT DATE: 12/06/2023

NARRATIVE

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LPA received the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

The following deficiencies were observed and cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

-at 12:17 pm, rusted metal rack, empty pail, dusty commode, rusted metal, styrofoam container, piece of wood in the backyard.
-at 12:30 pm, Glade spray, perotoneal cleanser and scissor in unlocked bathroom cabinet.
-at 12:34 pm, Lysol cleaning agent in unlocked ensuite residents' bathroom.
-at 2:15 pm, 2 staff First Aid certificates expired and 1 staff no First Aid certificate on file.
-at 2:20 pm, S2 has no LIC503 Health Screening and TB test result on file.
-at 3:40 pm. R1, R2, R3, and R5's beds have half bed rails but no doctor's order on file.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2023 06:30 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms 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 evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for Lysol, glade, scissor and perotoneal cleanser in unlocked bathrooms cabinets which pose an immediate health and safety risks to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Administrator locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/07/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2023 06:30 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for metal rack, empty pail, dusty commode, rusted metal, styrofoam container, piece of wood in the backyard which pose potential safety and/or personal rights risks to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Administrator to have the yard cleaned and submit pictures by 12/20/23.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the l icensee did not comply with the section cited above for 3 of 3 staff not having current/active First Aid certificates which pose a potential safety risks to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff and herself complete the training, and submit copies of certificates by 12/20/23.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2023 06:30 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician........ This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff (S2) not having LIC503 Health Screening and TB test result on file which pose a potential health and/or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff health screened and TB tested, and submit proof by 12/20/23.

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a)….. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 4 out of 5 residents not having doctor's order on file for half bed rails which pose a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Administrator to obtain doctor's order and submit copies by 12/20/23.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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