415600661-12-16-2023-14-AS-APAA-CYL77E-20231216202437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600661
Report Date: 12/15/2023
Date Signed: 12/16/2023 08:24:46 PM

Document Has Been Signed on 12/16/2023 08:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ELLE'S CARE HOME		FACILITY NUMBER:	415600661
ADMINISTRATOR:	LASTIMOSA,KARIN		FACILITY TYPE:	740
ADDRESS:	704 MADDUX DRIVE		TELEPHONE:	(650) 756-1351
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	6	CENSUS: 3	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Karin Lastimosa		TIME COMPLETED:	01:30 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 12/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Arsenia Villadarez and explained the purpose of the visit. It was asked at this time that SM Villadarez call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. LPA was able to speak to FDA Karin Lastimosa via telephone and it was learned that they were unable to come to the facility at this time due to other obligations. LPA was able to continue the visit with SM Villadarez. Current census was 2. 1 out 2 residents were out at their respective day program at this time. This facility is licensed to serve residents who are 60 and older. All 6 residents may be non-ambulatory. This facility also has a hospice waiver on file. LPA reviewed 2 resident files. It was observed that 2 out 2 residents did not have an updated physicians report and did not have a Needs and Appraisals Plan on file. LPA reviewed 3 staff files. It was observed that 1 out 3 staff files did not have an active First Aid Certificate at this time. The current administrator has a current administrator certificate #6018146740 and expires until 07/07/2024. A tour of the facility was conducted. Fire extinguisher was observed to be annual inspected on 11/14/2023 by Arrow Fire Protection Company. Smoke detectors and carbon monoxide was in good repair. A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food supply at this time. LPA observed a washer and dryer in the kitchen. Laundry soap was accessible at this time. LPA observed dish soap and toxins under the sink and was not locked and made inaccessible. LPA also observed a large part of the counter chipped off near the dishwasher. A medication cabinet was observed in the kitchen. Along with SM Villadarez, medication and medication dispensing logs were reviewed and compared. First aid kit was present and contained all the required components. A tour of 3 resident bedrooms were conducted. Furniture and other furnishings were observed to be in good repair at this time. A tour of 2 resident restrooms were conducted. LPA observed that one resident restroom did not have knob and observed water damage near the grab bar in the bathtub. It was stated that no residents use the tub at this time. Hot water temperature was taken to ensure it was within Title 22 regulations at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ELLE'S CARE HOME	FACILITY NUMBER: 415600661
	VISIT DATE: 12/15/2023

NARRATIVE

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A tour of one staff room was conducted.
A tour dining room, living room and all other areas intended for resident use were toured. Furniture and furnishings were observed to be in good repair.
A tour of the yard was conducted. Perimeter fence was observe to be stable and in good repair. Gates were observed to be in stable and in good repair. LPA observed a yellow string connected to the perimeter gate. LPA advised that the yellow string be taken off as it is a fire clearance issue.

LPA informed the Administrator that their annual fees are due and was provided a copy of their pin number. Administrator stated that annual fees will be paid by 12/18/2023.

The following forms were asked to be submitted and provided to CCL:
-LIC308
-LIC400
-LIC500
-LIC610E

A technical violation is being provided for Sections 87303(a) 87458(a), and 87506(b).

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, no deficiencies were observed during today’s visit. An exit interview was held, and a copy of the report was provided in-person.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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