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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600661
Report Date: 03/15/2024
Date Signed: 03/15/2024 10:39:42 AM


Document Has Been Signed on 03/15/2024 10:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ELLE'S CARE HOMEFACILITY NUMBER:
415600661
ADMINISTRATOR:LASTIMOSA,KARINFACILITY TYPE:
740
ADDRESS:704 MADDUX DRIVETELEPHONE:
(650) 756-1351
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:6CENSUS: 3DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Caregiver, Arsenia Villadarez TIME COMPLETED:
10:50 AM
NARRATIVE
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On March 15, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Caregiver, Arsenia Villadarez and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. Extra linen was observed. LPA toured four resident rooms; two of which are shared rooms and two are observed to be private resident rooms. All resident rooms were observed with all required furniture. LPA observed two full bathrooms. Bathrooms were observed clean and odor-free; equipped with liquid soap, paper-towels, and non-skid mats. LPA observed staff room located next to the bathroom. Extra linen supply was observed. First aid kit was present and complete.

Living room and dining room was observed to be free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Hot water throughout the facility measured at 115 degrees F throughout the facility. Sharps, toxins and medication were locked and inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of November 2023. LPA observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every four months.

LPA reviewed 3 resident records and 3 staff records. Resident records are updated, complete and signed, however during record review and tour, LPA observed that one resident (R1) has a foley catheter, however an exception was not approved by CCL. In addition, although LPA observed home health documents and doctor's discharge documents, LPA did not observe a service plan to show what home health is responsible for and what the facility staff will be responsible for. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with Caregiver and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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 2


Document Has Been Signed on 03/15/2024 10:39 AM - 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ELLE'S CARE HOME
FACILITY NUMBER: 415600661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file reviewed, LPA did not observe a service plan to care for R1's foley catheter or any document in writing for R1 to indicate what home health agency is responsible for and what the Licensee/caregivers are responsible for.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee/administrator shall complete a service plan for R1 and maintain it in R1's file. In addition, a copy of the completed and signed service plan for R1 shall be submitted to LPA by 3/22/2024.
Type B
Section Cited
CCR
87616(a)
(a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file reviewed, R1 does not have an exception to retain resident that has a restricted health condition. Based on file reviewed and observations, R1 has a foley catheter.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee/Administrator shall submit a written exception request to CCL for R1's foley catheter. Exception request shall include required documentation including but not limited to; training, service plan, discharge orders, R1's physician's report, etc. Licensee shall review CCR 87209, 87612, and 87613 as reference and submit all documents to LPA by 3/22/2024
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2