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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703573
Report Date: 04/12/2023
Date Signed: 04/12/2023 06:19:45 PM


Document Has Been Signed on 04/12/2023 06:19 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
WOODLAND HILLS NORTH, 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: 41DATE:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karena Higgins Interim Administrative AssistantTIME COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20230405151719). The purpose of the visit is to issue citations for deficiency observed during the complaint investigation which is not related to the complaint. Administrator Fe Higgins was contacted via phone and the reason for the visit was explained. Administrator was unable to be at the facility during today’s visit and authorized Karena Higgins to sign and receive the report, however administrator return to the facility by the end of business day and received and signed report.

During today's visit, administrator was unable to be at the facility and directed the LPA to staff Karena Higgins. However, based on the conversation staff Higgins was not able to assist LPA with documentation needed for the investigation. Staff further stated that she is not responsible and is unaware who the designee, lead staff or person in charge was.

Pursuant to Title 22 of the California Code of Regulations Division 6, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, administrator sign and receive report. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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 04/12/2023 06:19 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ELMS RESIDENTIAL CARE
FACILITY NUMBER: 561703573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited

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1569.618(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility...... when the administrator is temporarily absent from the facility.
This requirement is not met as evidenced by:
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Administrator Fe Higgins agreed to submit a LIC308 designating a staff to act on behalf of the administrator when unavailable by 04/19/2023.
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Based on interview and observation and request to speak with present administraor or designee the licensee did not comply with the above cited section, as there was no admistrator or designee present to assist LPA during the visit. Staff was unavable to provide necessary documentation (LIC500).
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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: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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