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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703573
Report Date: 03/16/2023
Date Signed: 03/16/2023 05:36:46 PM


Document Has Been Signed on 03/16/2023 05:36 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:
03/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Fe HigginsTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) KaSandra Lopez and Esther Cortez conducted an unannounced Case Management -Deficiencies inspection due to a deficiency observed during a complaint investigation. The LPAs met with Administrator Fe Higgins and explained the reason for report.

During today's inspections, the LPAs requested a copy of the food menu but the Administrator was unable to provide and there was no menu posted in the facility.

Based on this information, a deficiency is being cited.
Pursuant to Title 22 of the California Code of Regulations Division 6, the following deficiencies were cited (refer to LIC 809-D). Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/16/2023 05:36 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: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited

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87555 General Food Service Requirements (b)(6)In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days.
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The administrator agrees to keep a written menu at least one week in-advance and keep on file for at least 30 days. The administrator shall submit a copy of the menu to CCL by 03/23/2023.
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This requirement is not met as evidence by:
Based on observation and interview, the licensee failed to comply with the section cite above as the facility menu was not posted and the administrator did not have a copy of the menu which poses a potential personal rights to persons to 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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