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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803090
Report Date: 03/03/2022
Date Signed: 03/04/2022 03:39:07 PM


Document Has Been Signed on 03/04/2022 03:39 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ELANA BOARD AND CAREFACILITY NUMBER:
486803090
ADMINISTRATOR:CARTEL, JULLYFACILITY TYPE:
740
ADDRESS:236 CLYDESDALE AVETELEPHONE:
(707) 563-5252
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Jully CartelTIME COMPLETED:
01:58 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Jully Cartel and toured the facility. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. This facility is licensed for a total of 6 non ambulatory residents, with a Hospice waiver for 1. There are currently 5 residents in the home, of which one is out of the facility receiving rehabilitation services due to a recent fall.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing and Covid precautions. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices present: entry procedures, mask wearing, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed 12/24/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be clean at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged, and serviced 7/2021.
During today's visit facility reported resident R1 sustained a fall on 2/28/2022 and fractured their pelvic. R1 is said to be doing well, receiving rehab and will be returning to the facility tomorrow. Facility is in the process of submitting an incident report. LPA went over reporting requirements and incident reports to be submitted within 7 days.

No citations issued during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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