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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803090
Report Date: 01/08/2024
Date Signed: 01/09/2024 01:10:40 PM


Document Has Been Signed on 01/09/2024 01:10 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:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Jully Cartel, Administrator/LicenseeTIME COMPLETED:
05:23 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. There are currently 4 residents in care with 3 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 3 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. Infection control practices are present. Facility has a 30-day supply of PPE. Facility has also submitted their Infection Control plan, which is a part of their Plan of Operation.
Facility was found to be at a comfortable temperature with all exits free from obstruction. 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 10/24/2023. Smoke detectors and carbon monoxide detectors were tested and operational. Fire drills are conducted and the last one was documented on 10/23/2023. Water temperature in the resident bathroom was tested and found to be at 109 degrees F. and is within appropriate range of 105-120 degrees. Exit doors have auditory alarms to alert staff, but dining room sliding door will need new batteries soon. The bedrooms are all furnished as required, but LPA went over sufficient lighting in all resident rooms and some rooms may require an additional lamp. 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. 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 as they have dementia residents and regulation applies.

Resident and staff files were reviewed and resident files were in compliance. Staff files lacked proof of annual required training and CPR/1st aid was expired.
Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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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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: 01/08/2024
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The following deficiencies were observed:

· At approximately 4:05 PM during employee file review it was observed that required staff do not have proof of first aid training or CPR. Staff S1's CPR/1st aid expired 6/5/2023; staff S2 expired 6/6/2023 and staff S3 had no proof of either.



· At approximately 4:15 PM during employee file review it was observed that two staff present, did not have proof of the required annual training and Administrator explained they were in the process of completing.

Administrator submitted renewal paperwork for Administrator certificate for Jully Cartel.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 2/04/2024:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2024 01:10 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: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays record review of staff files 3 oout of 3 staff did not have current 1st Aid and no staff had proof of current CPR, LPA reviewed with Administrator and, the licensee did not comply with the section cited above in 3 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Facility to provide proof of current CPR for at least 1 staff present at all times and all staff to have 1st aid. POC due date 1/19/2024 Attention LPA Araceli Canela
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays staff record review, and statement from licensee, non of the staff had proof of required annual training, the licensee did not comply with the section cited above in 2 out of 2 staff did not have proof of training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Facility to provide proof of staff training and written plan on how facility will stay in compliance and provide the required staff annual training. POC due date 1/26/2024 Attention LPA Araceli Canela
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: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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