486803090-2-7-2025-21-AS-ACAA-DDP29Z-20250207161242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803090
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:14:12 PM

Document Has Been Signed on 02/07/2025 04:14 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/ DIRECTOR:	CARTEL, JULLY		FACILITY TYPE:	740
ADDRESS:	236 CLYDESDALE AVE		TELEPHONE:	(707) 563-5252
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	NicoleVillanueva		TIME VISIT/ INSPECTION COMPLETED:	04:20 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) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with care staff Nicole Villanueva(NV) and Ruby Agapito. Administrator, Jully Cartel was not available during the visit but authorized (NV) to sign reports. There are currently 4 residents in care with 2 staff at the time of inspection. This facility is licensed for 6 non-ambulatory residents, of which 1 can be bedridden and a hospice waiver approved for 3 of the residents. There are currently no residents receiving hospice services. LPA toured facility and grounds and observed all required signs posted in common areas, but poster PUB 475 was not in the required size, LPA issued an Advisory note and explained failure to correct may result in facility being cited. LPA also went over residents Admission and Plan of Operation, facility has a camera locate the living room and this must be disclosed in the plan of operation and admission agreement or be removed. LPA advised failure to correct will result in facility being cited. Facility was found to be at a comfortable temperature. LPA went over facility exit doors must be free from obstruction and requested resident R1s bed to be moved a little for easy exiting incase of an emergency. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguishers were fully charged, and have proof of service on 10/11/2024. Smoke detectors and carbon monoxide detectors were tested and operational. Fire drills are conducted and the last one was documented on 11/26/2024. Water temperature in the resident bathroom was tested and found to be 119 degrees F. and is within appropriate range of 105-120 degrees. Exit doors have auditory alarms to alert staff. The bedrooms are all furnished as required. Bathrooms were clean and sanitary with non-skid mats/floors and grab bars. The outside grounds have plants, fruit trees, and provide easy access for the residents to enjoy fresh air. Continue report see LIC809-C

Kimberley Mota	TELEPHONE: (707) 588-5051
Araceli Canela	TELEPHONE: (707) 588-5041
	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

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: 02/07/2025

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The 3 sheds in the back yard are for storage of equipment only and are pad locked. LPA went over requirements for yard gates that will need to be able to self close and latch if they care for any dementia residents. LPA also reminded facility to trim any bushes to make the path to exit doors clear at all times.
LPA went over reporting requirements and daily activities for residents. LPA also reminded facility to ensure they have a call system for residents to use, incase they need assistance as the bedrooms for residents and staff are not close to each other.

Resident and staff files were reviewed. Staff have proof of annual training and current CPR/1st expiring 1/30/2027.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 3/04/2025:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-
Copy of corrected plan of operation/Admission Agreement

Exit interview conducted. No citations issued during inspection,

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC809 (FAS) - (06/04)

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