486803090-3-9-2023-21-AS-DTOA-CPRSTG-20230309130930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803090
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:00:26 PM

Document Has Been Signed on 03/09/2023 02:00 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 CARE		FACILITY NUMBER:	486803090
ADMINISTRATOR:	CARTEL, JULLY		FACILITY TYPE:	740
ADDRESS:	236 CLYDESDALE AVE		TELEPHONE:	(707) 563-5252
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Jully Cartel, Licensee		TIME COMPLETED:	01:24 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	On 3/9/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required inspection for this facility and met with Licensee, Jully Cartel. The facility currently provides care for 5 residents 1 of which was at a physician's visit at the time of visit. One resident is receiving hospice services and some of which have a of diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/26/2022 at the time of the visit. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be participating in their individual activities including cleaning, resting and watching television. LPA also observed puzzles and coloring books available for use. Resident's appeared to be in a positive mood and in good relation with Licensee. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens. There was a supply of hygiene products and paper products available for resident use. Toxins and cleaning supplies are stored in the staff quarters and found to be secured. Sharps are also found in designated kitchen cabinet and found to be locked. All emergency exits and side gates were unobstructed. Three sheds located in the backyard were also found to be secured and inaccessible to residents. During inspection LPA found 2 auditory alarms in resident bedrooms leading outside the facility in need of repair. Licensee agrees to immediately install batteries for all inoperable alarms. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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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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
	VISIT DATE: 03/09/2023

NARRATIVE

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LPA Tobola conducted a spot medication review for 5 out of 5 clients and found all medications to be input correctly in the centrally stored medication records. LPA found that a resident (R5) was newly admitted and Licensee will be inputting recently delivered prescribed medications for R5.

LPA Tobola reviewed 5 out of 5 resident files and found that resident R2 and R4 need Physician's Reports updated. In addition, The Needs & Service Plan needs updating for residents, R1, R2, R3 and R4. Licensee agrees to review and schedule for document updates. Lastly, LPA Tobola conducted a file review for 4 out of 4 staff. LPA found that all staff have current CPR and 1st Aid and 20 hour of annual training on file. The facility conducted emergency evacuations every 3 months.

Licensee, Jully Cartel's Administrator Certificate 6006957740 is valid till 11/24/2023.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA requested the following documents be sent to CCL by COB 3/23/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/09/2023 02:00 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: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 5 auditory alarms at exits for persons with dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee agrees to immediately replace auditory alarms and/or batteries to ensure they are in operating condition. Licensee to submit LIC9098 Proof of Corrections to CCLD by POC due date 3/10/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/09/2023 02:00 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: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 residents' Physician's Reports and 4 out of 5 residents' Needs & Service Plans in need of updating, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Licensee agrees to schedule appointments for R2 & R4 to update Physician's Reports LIC602 and provide scheduled dates to CCLD by POC date 3/16/2023. Licensee to also update Needs & Service Plan LIC625 for residents R1, R2, R3 & R4. Updated documents to be submitted to CCLD by POC date 3/21/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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