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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202288
Report Date: 12/28/2022
Date Signed: 12/28/2022 01:12:19 PM

Document Has Been Signed on 12/28/2022 01:12 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:ELIM CARE HOMEFACILITY NUMBER:
435202288
ADMINISTRATOR:MARK SUNGFACILITY TYPE:
735
ADDRESS:15600 LA MAR DRIVETELEPHONE:
(408) 771-6275
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 3DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mark SungTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator (ADM), Mark Sung.

During visit, LPA toured the facility to include the kitchen, living room, bedrooms, bathroom, garage, and backyard. Staff present observed wearing a face covering.

A no visitor sign at the main entrance was observed. ADM immediately removed the no visitor sign. Facility has a sign-in sheet for all visitors. LPA strongly recommended to screen visitors and staff for symptoms of COVID-19 prior to entering the facility. The main entrance was supplied with hand sanitizer and posters for COVID-19. Bathroom supplied with hygiene products. ADM was informed the use of air dryers and cloth towels was discouraged. ADM was informed to place paper towels and a hand washing sign in the bathroom. LPA did not observe at least a 30 day supply of Personal Protective Equipment (PPE). Staff are not trained on infection control and are not N95 fit-tested.

ADM states a resident at the facility tested positive for COVID-19 back in 2021. ADM states to have notified other parties besides Licensing. LPA did not observe the facility reported a COVID case to the Department. ADM states to send special incident reports (SIRs) to San Andreas Regional Center (SARC) but not to Licensing.

The following documents were requested by 01/06/2023 to include: LIC610D, LIC500, updated facility sketch, and the facility's infection control plan.

A deficiency was cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Mark Sung and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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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Document Has Been Signed on 12/28/2022 01:12 PM - It Cannot Be Edited


Created By: Christine Dolores On 12/28/2022 at 12:49 PM
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: ELIM CARE HOME
FACILITY NUMBER: 435202288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure to inform the Department of special incident reports to include a resident testing positive for COVID-19 in 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2023
Plan of Correction
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Licensee will ensure to start sending the Department special incident reports and will review section 80061. Licensee will send a statement of understanding to LPA via email by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022


LIC809 (FAS) - (06/04)
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