Community Care Licensing

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023

Document Has Been Signed on 10/11/2023 07:40 PM - It Cannot Be Edited

FACILITY NAME: ELLEE RESIDENTIAL CARE #2	FACILITY NUMBER: 197602998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Type A

Section Cited

CCR

87309(a)(1)

(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 per tour of the physical plant, the cabinet under the kitchen sink that houses the knives and cleaning solutions and the garden shed that contained a bottle of Round Up Weed and Grass Killer was left unlock during the visit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that all cabinets that contain sharp knives, toxins, poisons or any item that could pose a risk to the residents in care are locked and made inaccessible at all times. The garden shed and the cabinet under the sink was locked at the time of the visit.

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 per review of facilty records, Sandra Yemima and Susanty Jakarta both hired on 8/29/23 were cleared on 8/15/223 but had not requested a transfer of their criminal record as of today's visit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that all staff, volunteers or any individuals who are required to obtain a criminal record clearance, also request a transfer of their criminal record clearance. Submit an original LIC9182, LIC508 with a legible copy of their driver license to request the transfer or contact Guardian to obtain an account and associate Sandra Yemima and Susanty Jakarta to the facility by POC datte - 10/12/23te. CIVIL PENALTIES WERE ASSESSED

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023

Document Has Been Signed on 10/11/2023 07:40 PM - It Cannot Be Edited

FACILITY NAME: ELLEE RESIDENTIAL CARE #2	FACILITY NUMBER: 197602998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Type B

Section Cited

CCR

87303(a)

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 per tour of the physical plant, it was observed that the backyard and side of the facility contained many items such as a vanity, glass sliding doors, mattress, plastic buckets, mirrors, ladders, wooden boards, plastic bins, sinks, mops, brooms, gardening tools that need to be stored away or discarded, over grown grass and weed need to be cut which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee shall ensure that the facility inside and outside are clean, safe, sanitary and in good repairs at all times. Licensee will discard or store all items that need to be retained from the backyard and along the sides of the facility and cut the overgrown weed and grass by POC date of 10/18/23

Type B

Section Cited

CCR

87307(a)(3)(B)

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 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 per tour of the resident bedrooms. Dressers were not observed in Bedroom #1 and Bedroom #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee will provide dressers to residents in Bedroom #1 and Bedroom #2 that meet Title 22 requirements of 8 cubic feet per resident by 10/18/23

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023

Document Has Been Signed on 10/11/2023 07:40 PM - It Cannot Be Edited

FACILITY NAME: ELLEE RESIDENTIAL CARE #2	FACILITY NUMBER: 197602998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Type A

Section Cited

CCR

87705(e)

Care of Persons with Dementia: (e)Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes 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 per tour of the physical plant, it was observed that the 12 feet deep facility pool had no water at the time of the visit and the netted fence did not meet state or local building codes. The netted fence did not secure the pool or make the pool inaccessible to the dementia resident in care or able to prevent a fall injury which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee will provide Licensing with a written plan of action as to how the swimming pool will be secured and made inaccessible for the dementia resident or any other resident from sustaining a fall injury until permanent measures can be made to secure the pool by 10/12/23. The licensee will notify the Department once the permanent measures have been completed.

Section Cited

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

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023

Document Has Been Signed on 10/11/2023 07:40 PM - It Cannot Be Edited

FACILITY NAME: ELLEE RESIDENTIAL CARE #2	FACILITY NUMBER: 197602998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Type B

Section Cited

CCR

87216(a)(1)

Bonding(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. (1) The amount of the bond shall be in accordance with the following schedule: Total Safeguarded Per Month Bond Required $750 or less $1,000 $751 to $1,500. $2,000 $1,501 to $2,500 $3,000 Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above per information obtained that the Facility is payee for Resident# 3's social security benefits and PACE program and has not maintained the the required Surety Bond in the appropriate amount which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that a current Surety Bond iwith the appropriate coverage is maintained by the facility if they plan to handle the residents' money or become payee for any resident.

Type B

Section Cited

CCR

87507(a)

Admission Agreement: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any 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 per review of Resident #2's file there was a blank Admission Agreemnt on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that an Admission Agreements are completed for every resident who is admitted to the facility, The Original will be maintained in the resident's file and a copy provided to the resident, conservator or responsible party by 10/18/23

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023

Document Has Been Signed on 10/11/2023 07:40 PM - It Cannot Be Edited

FACILITY NAME: ELLEE RESIDENTIAL CARE #2	FACILITY NUMBER: 197602998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Type B

Section Cited

CCR

87705(j)

Care of Person with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 per tour of the facility, it was observed that there is no auditory device installed on the front door, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that alll facility exit doors are installed with auditory devices or other staff alert features to monitor exiit and to conduct monthly checks to ensure that the battery is still in working order. Provide evidence that the auditory device has been placed on the front door by POC date

Type B

Section Cited

CCR

87307(a)(E)

Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided 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 per tour of the resident rooms bedroom #3 does not have a closet, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee will provide the resident in Bedroom #3 with a portable closet by POC date

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023

FACILITY NAME: ELLEE RESIDENTIAL CARE #2	FACILITY NUMBER: 197602998
	VISIT DATE: 10/11/2023