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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707150
Report Date: 08/08/2025
Date Signed: 08/08/2025 01:19:04 PM

Document Has Been Signed on 08/08/2025 01:19 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ELLIOTTS HOME IIFACILITY NUMBER:
430707150
ADMINISTRATOR/
DIRECTOR:		ELLIOTT, MARLENEFACILITY TYPE:
735
ADDRESS:1594 INVERNESS CIRCLETELEPHONE:
(408) 723-9423
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 0DATE:
08/08/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Loren GarciaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced facility closure visit and met with Loren Garcia.

LPA toured the facility inside and out. LPA toured the facility, including five out of five bedrooms, and observed there to be no residents in the facility. There were no resident personal belongings in the bedrooms or bathrooms. The facility had drawers and other furniture that Loren Garcia stated will be given away and donated. LPA Marrufo requests that the facility submit the original facility license by mail or in person at the CCL office by 08/15/2025.

Loren Garcia stated that there were three residents who lived in the facility before it closed. On 08/07/2025, Loren Garcia emailed LPA Marrufo with a line list of the three last residents at the facility, where they relocated, and the contact information for their social workers.

During visit, Loren Garcia stated the facility closed on 05/28/2025. The department did not receive any notification of facility closure until 08/04/2025 when Licensee/Administrator Marlene Elliot sent an email to the department stating that she has decided to close the facility and the facility property has been sold. On 08/07/2025, a facility staff sent an email to LPA Marrufo with a Plan of Closure document attached. The Plan of Closure document stated the facility would be sold and the closure date would be 05/28/2025. The document stated the transition process would begin on 04/21/2025.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Loren Garcia and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/08/2025 01:19 PM - It Cannot Be Edited


Created By: David Marrufo On 08/08/2025 at 10:26 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 II
FACILITY NUMBER: 430707150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2025
Section Cited
CCR
80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by: Licensee/Administrator did not notify the department within 10 days of
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Licensee/Administrator agrees to review CCL Title 22 Regulation 80064 Administrator Qualifications and Duties and submit a Statement of Understanding indicating that the Licensee/Administrator has understood his/her Qualifications and Duties as Administrator to CCL by Plan of Correction
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of the changes of the plan of operation of the facility, which poses an immediate safety risk to residents in care.
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date of 08/09/2025.
Type B
08/15/2025
Section Cited
CCR80061(e)(4)

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80061 Reporting Requirements (e) The items below shall be reported to the licensing agency within 10 working days following the occurrence. (4) Any changes in the plan of operation which affect the services to clients. This requirement was not met as evidenced by: Based on interview and record review,
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Licensee agrees to submit an Unusual Incident/Injury Report to the department within Plan of Correction date of 08/15/2025 reporting the facility closure, including the date of closure, date of sale of the facility property, and names of the last residents in the facility and their relocation sites.
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the Licensee/Administrator did not ensure that the department was notified via Unusual Incident/Injury Report of th facility closure within 10 working days of its closure, which poses a potential 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.
Maria Partoza
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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