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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706169
Report Date: 02/28/2024
Date Signed: 02/28/2024 08:55:21 PM

Document Has Been Signed on 02/28/2024 08:55 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ELLIOTTS HOMEFACILITY NUMBER:
430706169
ADMINISTRATOR:ELLIOTT, M & SFACILITY TYPE:
735
ADDRESS:2324 BEN HUR COURTTELEPHONE:
(408) 371-0195
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 2DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Marlene ElliottTIME COMPLETED:
11:56 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with administrator (ADM) Marlene Elliott. Facility licensee, administrator certificate and personal rights posters were observed posted in the facility. 2 clients went to day program.

LPA reviewed 2 client files and 2 staff files.

LPA toured the facility inside and out with ADM. LPA inspected living room, family room, kitchen, dinning area, and laundry room. 3 bedrooms, 1 master room and 2 bathrooms in the first floor. 2 bedrooms and 1 bathroom in the second floor. Knives closet, and cleaning product closet were observed locked. There are 2 bedrooms for residents in the second floor. There are 3 bedrooms, 1 master bedroom, and two restrooms for ADM family. Room temperature was observed at 68 degree F, and hot water temperature was observed at 106 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 05/30/2023. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated the facility has power generator and solar panel system. There was a swimming pool at backyard. There are fences with gates locked around the swimming pool. LPA observed the non skid mats in the bathrooms. First aid box was observed in the facility. The date of the last fire and emergency drill for the facility is 2/7/2024.

Deficiency noted during inspection. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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 02/28/2024 08:55 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/28/2024 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELLIOTTS HOME
FACILITY NUMBER: 430706169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record reviewed, the licensee did not comply with the section cited above in that 1 out of 2 client's centrally stored medication form was observed inaccurate which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Administrator stated he/she will submit a plan of correction by the POC due date to make sure residents' centrally stored medication forms are maintained up to date and accurate.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
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