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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600763
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:15:11 PM


Document Has Been Signed on 09/25/2024 03:15 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 2FACILITY NUMBER:
415600763
ADMINISTRATOR:LASTIMOSA, KARIN S.FACILITY TYPE:
740
ADDRESS:18 ROSALITA LANETELEPHONE:
(650) 872-1389
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 4DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee/Adminstrator - Karin LastimosaTIME COMPLETED:
03:30 PM
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On 09/25/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required 1 year inspection visit. LPA met with caregiver Jeremiah Slavador and explained the purpose of today's visit. There are 2 staff present and 4 residents in the facility. According to staff there are 3 GGRC residents and 1 RCFE resident. Around 245pm the licensee met with LPA Vado at the facility.

This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory and one bedridden. License is approved for 3 hospice residents. There are no residents on hospice as of this visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregiver. LPA observed the facility kitchen which is observed as in good working condition. Knives are stored and locked in a drawer adjacent to the sink. There is a locked cabinet beneath the kitchen sink but no cleaning supplies are present when observed. Perishable and non-perishable food supplies are observed as in place. There is an additional cabinet in the garage which stores additional canned goods and dry goods for resident and staff use. First aid kit is observed as complete with required items stored in the medication cabinet which is observed to be locked. LPA observed at least two fire extinguishers in place which are currently within operating range, combination smoke/carbon monoxide detectors are observed in place through out the facility, and central heating. A carbon monoxide detector in place located in a hallway was tested but it did not work. The facility had combination carbon monoxide/smoke detectors in place that did work. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA made observations of the exterior and observed items stored beneath the raised wooden walkway such as old bed frames, screen doors, a shopping cart, and old wheel chairs. Additionally LPA observed unlocked paint cans stored beneath the walkway. The paint cans pose an immediate health and safety risk to residents in care. Water temperature was measured in a resident bathroom at 122F and increasing during testing which poses as a health and safety issue for residents in care. In this same bathroom LPA observed cleaning solutions stored beneath the bathroom sink which poses an immediate health and safety risk to residents in care. Cleaning supplies are observed to be locked in the garage primarily.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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 4


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 2
FACILITY NUMBER: 415600763
VISIT DATE: 09/25/2024
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LPA did observe several items as not in good repair during the inspection such as: torn or missing window screens on resident windows, broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility, and a broken grab bar that is under repair per staff interview which can poses as a health and safety risk to residents in care. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Linen closet is observed as stocked with such items for resident use. Shower floors are equipped with non-skid mats or flooring as observed. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed four resident files and three staff files. Administrator certificate is expired as of 07/06/2024 but according to the administrator/licensee she has already renewed and is pending per administrator certification branch.

The following updated forms are requested to be submitted to CCLD by 09/30/2024:

• Copy of administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit regarding client/resident cash resources
• LIC402 Surety bond information with expiration date
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Citations are issued on this day on the attached LIC809D pages. Report is reviewed with licensee Karin Lastimosa and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/25/2024 03:15 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ELLE'S CARE HOME 2
FACILITY NUMBER: 415600763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2024
Section Cited
CCR
87309(a)

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87309(a)Storage Space -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.
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Can are removed by staff person Jeremiah during today's visit.

*** THIS POC IS CLEARED AND CORECTED DURING TODAY'S VISIT ***
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Based on facility observations made, LPA observed cleaning supplies stored beneath a resident bathroom sink unsecured. LPA also observed paint cans being stored beneath the raised wooden walkway located at the side of the facility and a can located near the side gate. This poses an immediate health and safety risk to residents in care.
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Type A
09/26/2024
Section Cited
CCR87303(e)(2)

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87303(e)(2) MAINTENANCE AND OPERATION - Water supplies and plumbing fixtures shall be maintained as follows: 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 degree C) and not more than 120 degree F (49 degree C).This regulation has not been met as evidenced by:
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Licensee shall submit a plan of correction on how the facility will maintain water temperatures between 105F and not more than 120F in faucets used by residents for personal care.
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Based on faciltiy observations made, LPA tested the water in a common resident bathroom in a hallway at the front of the facility. Water temperature was measured at 122F and increasing during today's visit. This poses an immediate health and safety risk to residents in care.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/25/2024 03:15 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ELLE'S CARE HOME 2
FACILITY NUMBER: 415600763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2024
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidenced by:
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Licensee shall submit a plan of correction in writing showing how the facility will maintain the facility in good repair at all times.
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Based on observations made, LPA observed that torn or missing window screens on resident windows, broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility, and a broken grab bar that is under repair per staff interview.
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Type B
09/30/2024
Section Cited
CCR87303(c)

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87303(c) Maintenance and operation - All window screens shall be clean and maintained in good repair. This regulation has not been met as evidenced by:
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Licensee shall submit a plan of correction showing all window screens that are not in good repair have been replaced and how the faciltiy will maintain them in good repair at all times.
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Based on observations made, LPA observed that several window screen through out the faciltiy are either damaged, ripped, or not in place. This posese a potential health and safety risk to residents in care.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4