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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703573
Report Date: 04/21/2023
Date Signed: 04/21/2023 06:24:54 PM


Document Has Been Signed on 04/21/2023 06:24 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:
04/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:28 PM
MET WITH:Angie Perez Assistant ManagerTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with a subsequent 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 Angie Perez to sign and receive the report.

During today's visit, administrator was unable to be at the facility and directed the LPA to staff Karena Higgins (S1), Angie Perez (S2) or any available staff. However, S1 is not associated with the facility. Prior to the visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS) and re-verified during the visit and S1 is not on the report. Interviews with the Administrator and staff revealed that S1 has been working at the facility from time to time over the years but no specific date was given. The LPA reminded the Administrator that staff that are not associated to the facility cannot be working at the facility. The Administrator stated that the facility will ensure all staff are associated to 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. Civil penalties issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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 04/21/2023 06:24 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2023
Section Cited

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87355Criminal Record Clearance (e)All individuals subject to a criminal ...(2)Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidence by:
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The licensee agrees to associate the staff to the facility immediately and submit proof by 04/22/2023. Civil penalties will continue to assess until the plan of correction is provided.
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Based on record review and interview the licensee did not comply with the section cited by not associating S1 to the facility 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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