561703573-7-10-2021-29-AS-KHEN-C5ELPT-20210730085629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 07/09/2021
Date Signed: 07/10/2021 09:37:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210701092939

FACILITY NAME:	ELMS RESIDENTIAL CARE		FACILITY NUMBER:	561703573
ADMINISTRATOR:	HIGGINS, FE LILIA 98		FACILITY TYPE:	740
ADDRESS:	67 EAST BARNETT		TELEPHONE:	(805) 643-2176
CITY:	VENTURA	STATE: CA	ZIP CODE:	93001
CAPACITY:	54	CENSUS: 41	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Fe Higgins		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to keep the facility clean

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angel Ascencio conducted an unnanounced initial 10-day complaint
inspection for the allegation listed above. LPA met with Administrator Fe Higgins at 10:20 AM. LPA then met with staff member #1 (S1) at 10:55 AM. Entrance interview conducted.

LPA interviewed S1 at 10:55 AM. At 11: 20 AM LPA obtained a copy of resident roster, staff schedule and housekeeping schedule. LPA and S1 conducted a physical plant tour at 11:27 AM. LPA conducted interviews between 11:55 AM and 12:38 PM.

Regarding the allegation: staff failed to keep the facility clean. During S1 interview at 10:55 AM, it was stated that residents in the facility tend to eat in their rooms and leave crumbs and trash on the floor. S1 also mentioned that some residents don't allow staff members in their rooms to clean.

CONTINUED ON LIC 9099 - C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20210701092939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 07/09/2021

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
26
27
28
29
30
31
32

S1 added there is housekeeping daily. During resident #1 (R1) interview at 11:55 AM, it was stated that the rooms are bad and not cleaned often. R1 stated their room and restroom hasn't been cleaned in 2-3 weeks. R1 thinks the facility is short staffed and require more help. During staff #2 (S2) interview at 12:02 PM, S2 stated they only mop and sweep living room and dining room after meals. S2 also added they need extra help to clean rooms and restrooms. During staff #3 (S3) interview at 12:16 PM, S3 stated they do daily cleaning, but the resident are quick to make a mess. During resident #2 (R2) interview at 12:21 PM, it was stated that the building is kept in good shape. R2 also added that their room and restroom are clean and is satisfied with the cleanliness. At 12:24, interview was conducted with staff #4 (S4). S4 stated that the cleaning of the building could be better. S4 added that due to lack of staffing or no show of staff, rooms don't get cleaned, trash doesn't get pick up which makes the other staff members pick up the slack. S4 adds that some residents are messy that they need their rooms cleaned 2x (times) a day. S4 also said that hallways and common areas are clean but some rooms, more than others need more cleaning. During resident #3 (R3) interview it was revealed that the rooms and restrooms could be cleaner. R3 also added that now they are sweeping and picking up in rooms daily but it takes weeks for the facility staff to clean the restroom. During resident #4 interview at 12:38 PM, it was revealed that their rooms does not get mopped often. R4 added they have to beg the staff and admin to clean room and restroom. R4 also mentioned that restroom gets cleaned 2-3x (times) a month. R4 also said that the hallway shower are clean but the facility needs to clean and mop the rooms and restrooms.

Based on observation and interview, there is sufficient evidence to support the claim; Staff failed to keep the facility clean. Therefore, this allegation is deemed substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of
Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210701092939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/23/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Admin stated they would create a better schedule for cleaning residents rooms and restrooms. Schedule of modified housekeeping to be provided to LPA via email.
	8 9 10 11 12 13 14	Based on LPA's observations and interviews, the licensee did not comply with the section cited above as 4 out of 41 residents and 4 staff members stated the resident rooms and restrooms could be cleaner which poses potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3