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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881116
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:59:44 PM


Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ELIAA, LLCFACILITY NUMBER:
331881116
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:11545 DOVERWOOD DR.,TELEPHONE:
(650) 656-7941
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:6CENSUS: 6DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Facility Manager Amirr YounesTIME COMPLETED:
05:10 PM
NARRATIVE
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On 03/21/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was one (1) staff present, and six (6) residents present. House Manager Ahmed Qasim and Administrator Amirra Younes were contacted and informed of the visit. Facility Manager Amirr Younes arrived during the visit. LPA Brown explained the purpose of the visit to Facility Manager Amirr Younes.

The facility is a nine (9) bedroom, three (3) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #5 (S5) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space, lamps and chair. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. LPA Brown measured and observed the water temperatures in the bathroom to be at 169.4 degrees F. Deficiency will be issued. House Manager regulated the hot water temperature to 106 degrees Fahrenheit during the visit. LPA Brown observed no night lights maintained in hallways and passages to nonprivate bathrooms at the facility. Deficiency will be issued. House Manager Younes purchased night lights during the visit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area.

Moreover, during the tour of the facility, LPA Brown observed knives drawer not locked in the kitchen, accessible to residents in care. ***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116
VISIT DATE: 03/21/2024
NARRATIVE
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In addition, LPA Brown observed cleaning solutions, bleach in the laundry area and readily accessible to residents in care. Also, LPA Brown observed cleaning solutions, bug killers stored under the bathroom sink, readily available to residents in care. Knives cabinet were also observed not locked and knives accessible to residents in care. Deficiency will be issued. House Manager Younes locked the chemicals, cleaning solutions, toxics and knives during the visit. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication room. LPA Brown found medications pre-poured for the week for Resident #1 (R1). LPA Brown explained that no medications shall be transferred between containers. Deficiency will be issued.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator and house managers. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA Brown observed Resident #2 (R2) does not have Pre-Admission Appraisal. Deficiency will be issued. Also, LPA Brown observed no updated Physician Report (LIC602) for Resident #3 (R3), last LIC602 Physician signature date's 01/07/2006. Deficiency will be issued. LPA Brown observed no staff files available to review for Staff #5 (S5), Staff #6 (S6) and Staff #7) for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. Deficiencies will be issued. Furthermore, LPA Brown obtained information that two (2) adult individuals were living at the ground floor of the two (2) storey house at the back of the facility. Per documents review, the two (2) individuals reported don't have criminal background clearance and have been living at the facility since 01/05/2024. Deficiency will be issued and civil penalty of $500.00 per individual will be assessed during today's visit and will continue to be assessed of $100.00 per day, per individual until corrected. Medication Audit were completed for three (3) residents. LPA Brown observed that Staff #5 (S5) dispensing Resident #1, Resident #2 and Resident #3 medications and not updating R1, R2 and R3 Medication Administration Record (MAR) per physician's directions. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to House Manager Amirr Younes.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by pre-pouring Resident #1 (R1) medication for the week which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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2
3
4
Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of staff training log to LPA Brown at Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by dispensing Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) medication and not updating R1, R2 and R3
Medication Administration Record (MAR) per physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87465(c)(2) and submit proof of all staff training log to LPA Brown at POC due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not regulating the hot water temperature of not less than 105 degrees F and not more than 120 degrees F in the residents shared bathroom as it measured 169.4 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee regulated the hot water temperature to 106 degrees F during the visit. Plan of Correction (POC) cleared.
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaining night lights in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee purchased night lights for the hallways and passages to nonprivate bathrooms during the visit. POC cleared.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Staff #5 (S5) complete the required cardiopulmonary resuscitation (CPR) training and first aid training as S5 is on duty and on premises at all times at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee stated to have S5 complete the required CPR and First Aid Training and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Staff #5 (S5), Staff #6 (S6) and Staff #7 (S7) staff file maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee stated to maintain complete S5, S6 and S7 staff file at the facility and submit proof to LPA Brown at Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
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Based on observation, interview and record review], the licensee did not comply with the section cited above by not having Staff #5 (S5) complete a Health Screening Report with a Physician which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee stated to have S5 complete a Health Screening Report and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on observation, interview,record review, the licensee did not comply with the section cited above by not having Staff #5 complete a Tuberculosis (TB) Test and no TB Test result availabe at the facility for S5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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2
3
4
Licensee stated to have S5 complete a TB Test and submit a copy of TB Test result to LPA Brown at POC due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required Pre-Admission Appraisal for Resident #2 (R2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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2
3
4
Licensee stated to submit Signed Statement of Understanding on CCR 87456(a)(2) to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an updated Physician Report (LIC602) for Resident #3 (R3) as R3's Physician Report physician signature date atthe facility's 01/07/2006 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a copy of R3's updated Physician Report to LPA Brown at Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 03/25/2024 02:14 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/25/2024 12:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(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, interview, and record review, the licensee did not comply with the section cited above by not locking the knives drawer in the kitchen, cleaning solutions and bleach in the laundry area and cleaning solutions, bug killers under the bathroom sink that are accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87309(a) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance (e) All individuals subject to criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(1) Obtain a California clearance...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing two (2) individuals to live at teh adjacent two-storey building located at teh back of the facility compound without criminal background clearance since 01/05/2024 which poses an immediate health, safety or personal rights risk to persons in care.***This is an amended copy as civil penalty will need to be modified with the amount of $500.00/individual***
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Licensee stated to have the two (2) individuals obtain criminal background clearance and submit proof to LPA Brown at Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 03/21/2024 04:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assist residents with the self administration......(2) In facilities licensed to provide care for 15 or fewere persons, the employee shall complete 10 hours of initial training. This training shall consists...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited aboveby not providing the required 10 hours of training to Staff #5 (S5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
1
2
3
4
Licensee stated to provide the required 10 hours of training on S5 and submit proof to LPA Brown at Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9