<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803090
Report Date: 04/20/2022
Date Signed: 04/22/2022 12:27:13 PM


Document Has Been Signed on 04/22/2022 12:27 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: 6DATE:
04/20/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Jully CartelTIME COMPLETED:
01:04 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Canela conducted an unannounced Case Management visit and met with Administrator, Jully Cartel. The purpose of this visit it to follow up on a previous visit to this facility. During facility visit of 3/3/2022, the facility reported resident R1 sustained a fall on 2/28/2022 and fractured their pelvic. R1 was said to be doing well, receiving rehabilitation and will be returning to the facility on 3/4/2022. Facility stated they were in the process of submitting an incident report and that incident had occurred 2/28/2022, in which the facility would meet the 7 day reporting requirement.

On 3/4/2022 LPA Canela received the incident report in which report stated incident for R1 occurred on 2/20/2022 and not on 2/28/2022 as what was stated to LPA. Facility failed to report the incident to CCL as required within 7 days; LPA went over reporting requirements.
In addition, during today's visit facility disclosed they have 3 residents receiving Hospice services and facility did not report hospice admission. LPA will correct the facility license as per the Hospice waiver that was approved for 3 residents on 1/31/2017. LPA went over and provided Regulation for 87632(d)(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. LPA went over facility reporting any cases of Covid-19 immediately to CCL and Local Public Health.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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 04/22/2022 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 486803090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited

1
2
3
4
5
6
7
87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the person the following: (1) A written report shall be submitted to the licensing agency & to responsible for the resident
8
9
10
11
12
13
14
within 7 days of the occurrence .....This requirement was not met vas evidenced by: facility did not submit the required report within the 7 days for R1. This is a potential risk to the H&S of residents in care.
8
9
10
11
12
13
14
POC due date 5/6/2022 to LPA Araceli Canela by email or fax.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2