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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600763
Report Date: 09/16/2019
Date Signed: 09/17/2019 08:34:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 5DATE:
09/16/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Caregiver In Charge, Edmund OngTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raygoza conducted an unannounced Required - 1 year inspection and met with Caregiver In Charge, Edmund Ong. There were five residents and two caregivers present during visit. In Living room, two residents were waiting for transportation to attend day program. Tour began in the kitchen and LPA checked the two day and seven day nonperishable food supply and was not sufficient. LPA observed the 7 day nonperishable food supply to be lacking in fruits and vegetables for 5 residents. Medication was observed to be in a locked cabinet. Kitchen tools and knives were in a locked drawer. Chemicals and cleaning supplies were observed in a locked storage area in garage. LPA resumed tour to the dining room. There are six private bedrooms with three shared bathrooms. Bedrooms #2 and #1 have heavily soiled areas on carpet and in need of repair. Carpet to be deep cleaned or replaced. The resident's bedrooms have adequate lighting and furniture. Room temperature is comfortable. In resident's bathroom all showers have grab bars, non-slip mats and nonskid floors. Working phone on premises (650) 872-1389. Smoke detectors and carbon monoxide detector present on premises. Disaster/Fire drills are conducted every six months. The Emergency Disaster Plan and Ombudsman's poster along with other CCL forms are visibly posted. Exterior grounds of the facility have clear passageways and are free of obstruction. LPA observed in the backyard debris as follows: four timeworn wheel chairs and a supermarket store shopping cart all to be removed from premises. Front door screen door is out of commission and in need of repair. There are no accessible bodies of water. Alarms are installed and operable. Staff and resident files randomly viewed. Medication logs randomly viewed.

The following forms to be submitted to CCL Office by 9/30/19:
LIC 308 Administrative Responsibility Designation
LIC 500 Personnel Report
LIC 309 Administrative Organization

Deficiencies found today under Title 22, Division 6, on following page LIC 809D. Appeal Rights given.
This report was reviewed, discussed and a copy given to Caregiver In Charge, Edmund Ong.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2019
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, 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: 09/16/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2019
Section Cited

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87555(b)(26) General Food Service Requirements -The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by: Licensee failed to ensure that the 7 day nonperishable food supply be adequate and sufficient for five residents. The 7 day nonperishable food is lacking in fruits and vegetables for five residents.
Type B
09/30/2019
Section Cited

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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 is not met as evidenced by: Licensee failed to keep carpet in bedroom # 2 and #1 well maintained and carpet is in need of repair. Carpet has heavily soiled areas. Carpet to be deep cleaned or replaced.
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Licensee failed to keep facility premises well maintained as Front door screen door is out of commission and in need of repair. In backyard there are four timeworn wheel chairs and one supermarket store shopping cart on premises all to be removed.
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2019
LIC809 (FAS) - (06/04)
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