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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703573
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:26:27 PM


Document Has Been Signed on 01/06/2023 04:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ELMS RESIDENTIAL CAREFACILITY NUMBER:
561703573
ADMINISTRATOR:HIGGINS, FE LILIA 98FACILITY TYPE:
740
ADDRESS:67 EAST BARNETTTELEPHONE:
(805) 643-2176
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY:54CENSUS: 42DATE:
01/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Fe HigginsTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management – Deficiencies visit at this facility. At 9:51 a.m., the LPA met with Administrator Fe Higgins.

At 10:09 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Prior to visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Interviews conducted from a complaint visit on 01/06/2023, revealed the facility was short staffed and the Administrator asked Individual #1 (I1) to work at the facility and help out with laundry. Per record review, conducted by the LPA on the Guardian website, I1 does not have fingerprint clearance. Interviews with the Administrator and staff revealed that I1 worked at the facility two weeks ago but no specific date was given. The LPA reminded the Administrator that staff that are not fingerprinted or are not associated to the facility cannot be working at the facility. The Administrator stated that the facility will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $100. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, today's reports and appeal rights were provided via email Civil penalties issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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Document Has Been Signed on 01/06/2023 04:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ELMS RESIDENTIAL CARE
FACILITY NUMBER: 561703573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2023
Section Cited

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87355(e)(1)Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... as required by the Department or
This requirement is not met as evidenced by:
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Licensee agreed that I1 will not work until I1 gets clearance. I1 has worked at the facility. Plan of correction met.

Civil Penalties assessed in the amount of $100.
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Based on record review and interview the licensee did not comply with the section cited by not getting a criminal record clearance for I1 which poses an immediate health, safety and personal rights risk to persons in care.
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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 HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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