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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881116
Report Date: 04/04/2024
Date Signed: 04/04/2024 01:05:24 PM

Document Has Been Signed on 04/04/2024 01:05 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/
DIRECTOR:		YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:11545 DOVERWOOD DR.,TELEPHONE:
(650) 656-7941
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 6CENSUS: 6DATE:
04/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Licensee/House Manager Ahmed QasimTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 04/04/2024 at 11:45 AM, Licensing Program Analysts (LPAs) Melody Brown and Sarina Ramirez conducted an unannounced visit to the facility in order to verify clearance of plans of correction created with Licensee/House Manager Ahmed Qasim, from visit on 03/21/2024. LPAs Brown and Ramirez met with Administrator Amirra Younes. Licensee/House Manager Ahmed Qasim was contacted and arrived during the visit.

The following Plan of Correction (POC)s were cleared at the time of the visit:

The Licensee was cited on 03/21/2024 for 87355(e)(1) Criminal Record Clearance for allowing two (2) individuals to live at the adjacent two-storey building located at the 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. Based on observation on 03/21/2024 and 03/25/2024, Licensee continued to allow the two (2) individuals to live at the adjacent two-storey building located at the back of the facility compound without criminal background clearance. The plan of correction (POC) was to obtain S5 Criminal Record Clearance. Therefore, POC was not cleared, and Civil penalty will be assessed in the amount of $100 per day for four (4) days. On 03/26/2024, Licensee Qasim submitted the criminal background clearance of the two (2) individuals that live at the adjacent two-storey building located at the back of the facility. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 03/21/2024 for HSC 1569.618(c)(3) Other Provisions. On 03/26/2024 Licensee Qasim submitted Staff #3 (S3) CPR and First Aid Training. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 03/21/2024 for 87412(g) Personnel Records. On 03/22/2024, Licensee Qasim submitted proof of Personnel Records maintained at the facility. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit. *** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116
VISIT DATE: 04/04/2024
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The Licensee was cited on 03/21/2024 for CCR 87412(a)(11). On 03/26/2024, Licensee Qasim submitted proof of completed Staff #5 (S5) Health Screening Report with a Physician. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 03/21/2024 for CCR 87412(a)(12) Personnel Records. Licensee Qasim submitted proof of Staff #5 negative Tuberculosis (TB) Test Result on 03/26/2024. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 03/21/2024 for CCR 87456(a)(2) Evaluation for Suitability for Admission. Licensee Qasim submitted proof of completed Resident #2 (R2) Pre-placement Appraisal on 03/26/2024. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 03/21/2024 for CCR 87456(a)(3) Evaluation of Suitability for Admission. Licensee Qasim submitted proof of updated Physician Report (LIC602) for Resident #3 (R3) on 03/31/2024. LPAs Brown and Ramirez provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 03/21/2024 for HSC 1569.69(a)(2). Licensee Qasim submitted proof of Staff #5 (S5) Training Log on 03/26/2024. LPA Brown and Ramirez provided a clearance letter for this deficiency during the visit.

An exit interview was conducted and this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided to Licensee/House Manager Ahmed Qasim.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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