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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703573
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:17:01 PM


Document Has Been Signed on 08/23/2022 02:17 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:
8056432176
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY:54CENSUS: 42DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Fe HigginsTIME COMPLETED:
02:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Administrator Fe Higgins.

LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 136 and 116 degrees F. in resident bathrooms. There is an adequate amount of perishable food. PPE supplies were observed. LPA observed the fire extinguishers fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. LPA observed appropriate lighting in residents rooms. LPA observed medications in locked medication room. Outdoor area toured- passageways are free of obstruction.

During facility tour with Administrator at 12:50 pm LPA did not observe an adequate supply of non-perishable fruit as the facility had 9 small and 1 large cans of fruit.

During facility tour at 1:05 pm with Administrator LPA observed comet and lysol toilet bowl clean in resident bathroom accessible to residents.

During facility tour at 1:07 pm with Administrator LPA observed hot water temperature at 136 degrees F. in resident bathroom.

During facility tour at 1:15 pm with Administrator LPA observed spray disinfectant on a hallway table accessible to residents.

Continued on 809C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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 4


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
VISIT DATE: 08/23/2022
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Civil penalties issued in the amount of $250.00.

Exit interview was conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/23/2022 02:17 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: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as the hot water temperature read at 136 degrees F. in resident bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Administrator stated that they will maintain hot water temperature at 105 to 120 degrees F. and will provide documentation that the hot water heater temperature was turned down to CCL by 8/24/22.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above as disinfectant and cleaning solutions were accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Administrator placed disinfectant and cleaning solutions in a locked medication room during the facility visit. Administrator stated that they will provide documentation of scheduled staff inservice regarding regulation 87309(a) to CCL by 8/24/22.

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) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/23/2022 02:17 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: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as the facility does not have a one week supply of nonperishable fruit which poses a potential health and personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Administrator stated that they will provide documentation of a one week supply of nonperishable fruit to CCL by 8/30/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4