374602750-4-13-2023-08-AS-DNGN-CQV298-20230413171130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602750
Report Date: 04/13/2023
Date Signed: 04/13/2023 05:11:38 PM

Document Has Been Signed on 04/13/2023 05:11 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ELMIRA HOME CARE		FACILITY NUMBER:	374602750
ADMINISTRATOR:	JENKINS, VALERIE		FACILITY TYPE:	735
ADDRESS:	361 ELMIRA STREET		TELEPHONE:	(619) 749-9761
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY: 4		CENSUS: 4	DATE:	04/13/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	DSP Javetta Taylor		TIME COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Javetta Taylor.

Today's visit was in response to a Special Incident Report (SIR) regarding Client #1 (C1), which licensee self-submitted to the CCLD San Diego Regional Office on 04-09-2023. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. According to the SIR: on different two days in late March 2023, C1 verbally threatened to cut/stab staff with a knife, but C1 did not try to act on these threats. Staff checked C1’s room but found no sharp objects. Then on 04-01-2023: during a check of C1’s bedroom, staff found multiple cooking knives inside a bag and immediately removed/secured them. C1 became upset and walked away from the facility. Facility staff followed C1 and maintained line-of-sight supervision, until C1 was ready to walk back to the facility with staff. Staff notified law enforcement, who interviewed C1 that day, but determined they did not meet criteria for a California Welfare & Institutions Code 5150 hold.

During today’s visit, LPA briefly toured the facility and performed a welfare check and interviews with the four (4) clients in care, verifying that all were unharmed/uninjured. LPA also reviewed pertinent care and medical records and interviewed relevant staff. Client and staff interviews essentially corroborated the details/veracity of the SIR. LPA observed no sharp or dangerous objects accessible to clients.

Per interviews of staff and C1 themselves: the cooking knives which staff located inside C1’s bedroom on 04-01-2023 were not from the facility. Rather, C1 obtained the knives from the off-site home of a trusted person C1 had prior visited (without that person being aware that their knives were taken). CCLD determined that licensee was not culpable for this.

[CONTINUED ON LIC 812-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELMIRA HOME CARE	FACILITY NUMBER: 374602750
	VISIT DATE: 04/13/2023

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[CONTINUED FROM LIC 809]

Staff interviews revealed that while C1 verbally threatened staff on two occasions in March 2023, since moving in, C1 had not acted or spoken aggressively towards any other client in care at this facility. Per interviews of C1’s three housemates: each felt safe living at the facility, and none felt threatened by C1’s presence.

C1 told LPA that the prior verbal threats they made to staff were done in anger, but they did not seek to harm anyone. C1 also agreed that facility staff were justified in confiscating the cooking knives.

The preponderance of evidence shows staff provided needed observation to keep clients safe, and that staff interventions did not constitute a violation of C1’s personal rights.

An exit interview was conducted with Taylor, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

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