198320483-12-4-2025-11-AS-MLEN-DP32GZ-20251204162357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320483
Report Date: 12/04/2025
Date Signed: 12/04/2025 04:24:06 PM

Document Has Been Signed on 12/04/2025 04:24 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ELLERY CARE HOME		FACILITY NUMBER:	198320483
ADMINISTRATOR/ DIRECTOR:	GUIAO, JOSEFINA		FACILITY TYPE:	735
ADDRESS:	902 S ELLERY DR		TELEPHONE:	(213) 880-5505
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY: 4		CENSUS: 3	DATE:	12/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:24 PM
MET WITH:	Bernard Basilan		TIME VISIT/ INSPECTION COMPLETED:	04:40 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	On 12/04/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual visit. LPA was met by staff one, Bernard Basilan (S1) and the purpose of the visit was explained. The facility is licensed to serve four (4) residents of which three (3) may be non-ambulatory. The facility is a single-story home in a residential neighborhood. It consists of four (4) resident rooms, kitchen, dining room, living room/office area and a shaded outdoor sitting area. All walkways around the home were observed clean, clear, and free of debris/obstructions. The indoor temperature was at a comfortable 72.9 degrees Fahrenheit (°F) and the fences open from the backyard to exit. LPA inspected the four (4) resident bedrooms and found them to be clean and in good repair. The department observed the bedrooms have the required furniture including a bed, dresser, nightstand with a lamp, chairs, and ample storage space for residents’ personal belongings. The department observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. The department observed an ample supply of linens in a cabinet in the hallway, in good repair. LPA inspected two (2) bathrooms in the facility. All bathrooms were found to meet Title 22 regulations. All bathrooms were observed operable. The showers were observed clean, and clear of mold or mildew. The showers had secured safety handrails, nonskid mats, and shower chairs. The water temperature measured within title 22 regulation. LPA observed an ample supply of towels in a cabinet in the hallway and an additional supply stored in residents’ closets, as well as ample linens. LPA inspected the kitchen and found it to be clean and sanitary. All appliances were observed to be in good repair and are operable. The department observed an ample supply of cook ware, dishware, and cutleries. The department observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly packaged and stored. Additionally, LPA observed an emergency supply of non-perishable food, stored above resident files. Report continues, please see LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ELLERY CARE HOME	FACILITY NUMBER: 198320483
	VISIT DATE: 12/04/2025

NARRATIVE

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All knives and sharps were observed secured in a locked toolbox in the kitchen and are inaccessible to residents. All cleaning supplies were observed secured in a locked cabinet out in the backyard seating area and are inaccessible to clients in care. An additional supply of cleaning products were observed secured in the laundry area, inaccessible to clients in care.
LPA observed smoke detectors and a carbon monoxide detector and all were in operable condition. The last fire drill was conducted on and the annual maintenance of two (2) fire extinguishers were last conducted on 03/25/25, both extinguishers displaying a full charge.

LPA reviewed four (4) clients' files, no discrepancies were observed. LPA reviewed one (1) clients' medication administration file, no discrepancies were observed.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with Bernard Basilan - Assistant Administrator and a copy of this report has been provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC809 (FAS) - (06/04)

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