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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202311
Report Date: 03/23/2024
Date Signed: 03/23/2024 05:29:45 PM

Document Has Been Signed on 03/23/2024 05:29 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:ELLIOTT HOME IIIFACILITY NUMBER:
435202311
ADMINISTRATOR:MARLENE ELLIOTTFACILITY TYPE:
735
ADDRESS:1880 WHITE OAKS RD.TELEPHONE:
(408) 371-0195
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 4DATE:
03/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager/Amber Elliott -TIME COMPLETED:
05:30 PM
NARRATIVE
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On 3/23/2024 at 2:00 p.m., Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced Required 1 year inspection and met with facility house manager/administrator in training (HM/ADM) Amber Elliott. Administrator Marlene Elliott, was not available due to a family emergency.

At the time of the visit HM/ADM stated the current census is 4 and and herself as the staff.

LPA with HM/ADM toured the facility including but limited to the following area of the facility, living room, kitchen, dining room, bedrooms, bathrooms, laundry room, and exterior perimeter. The facility provides shoe covers for visitors who enters the facility.

At 2:15 p.m. LPA observed the kitchen to be clean and free from any debris, knives are in a locked drawer, chemicals are stored separately in a locked cabinet. Residents' room are well maintained and are free from debris and kept organized. The exterior walkways and designated as emergency exits are free from obstructions. LPA observed the bathroom has a non-skid mat, grab bars, and well maintained.

LPA observed refrigerator temperature at 38 degree F and freezer is at 0 degree F with 2 days perishable food supply. The pantry was organized and has 7 days of non-perishable food supply.


page 1 continued to page 2 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2024
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 03/23/2024 05:29 PM - It Cannot Be Edited


Created By: Maria Partoza On 03/23/2024 at 04:07 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: ELLIOTT HOME III
FACILITY NUMBER: 435202311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4
85075.4 Observation of the Client(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 4 out of 4 persons in care does not have a weight record on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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House manager stated thst he/she was not aware of the weight record is required to have on resident's file folder and be monitored and recorded at least once a month by the licensee. HM stated he/she will start the weight record for all residents in care starting 03/24/2024. A plan of correction will be submitted to LPA by 4/5/2024.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2024


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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ELLIOTT HOME III
FACILITY NUMBER: 435202311
VISIT DATE: 03/23/2024
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LPA observed 2 smoke and a carbon monoxide detector. The detectors were observed to be fully operational. Facility temperature observed to be 69 degree F, water temperature measured between 105 to 120 degree F.

LPA reviewed 4 resident record (R1 to R4) and 2 staff record (S1 to S2). LPA observed that 4 out of 4 residents does not their weight records on file. LPA reviewed 2 staff records and found the record to be updated.

The facility has updated disaster plan in place and disaster training is up to date.

During today's visit, a citation is being issued per California Code of Regulations (CCR) Title 22. An exit interview was conducted with HM/Administrator Amber Elliott and a copy of the report was provided with the appeals rights.

end of report
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2024
LIC809 (FAS) - (06/04)
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