Ellery's Family Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Junell Evanglista. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began- Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application-1 missing, health screening-1 missing and TB test results, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and expires 6/5/2027. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 109.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on next page) (Continued from Page 1) Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan however a resident that is designated as bedridden was not in approved bedroom according to the fire safety inspection. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was not tested or replaced annually and were last done so on 02/4/2025. The facility is conducting emergency disaster drills monthly and done on 2/28/2026. Based on the information received during this visit today, there are seven (7) deficiencies is being cited with Civil Penalties of $1,000 being issued per Title 22, Division 6 of The California Code of Regulations. This report, LIC809D, LIC421IM and Appeal Rights was reviewed with Junell Evangelista and a copy provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Mar 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began- Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements. LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have not been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 120.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on next page) (Continued from Page 1) Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan however a resident that is bedridden was not in approved bedroom according to the fire safety inspection. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 02/4/2025. The facility is conducting emergency disaster drills. The facility is not conducting last disaster drills. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are six (6) deficiencies is being cited with Civil Penalties of $500 being issued per Title 22, Division 6 of The California Code of Regulations. This report, LIC809D, LIC421IM was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview. LPA has requested updates to the following documents to be submitted to the CCL by 03/28/2025: LIC 500the state’s words, verbatim · CDSS document, Mar 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with caregiver Leondro Valenzuela who was informed of the purpose of the visit. Licensee Ellery Jane arrived during LPA's visit. At the time of the visit there was two (2) staff and six (6) residents present. The facility has a hospice waiver for six (6) residents. A dementia program is also on file. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were locked and inaccessible to residents. The sharp and dangerous objects was locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108 degree F, which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. The listed administrator possesses a current administrator's certificate. Six (6) resident files were reviewed, and possessed all required paperwork that included Admissions Agreement, Physician's Report, and Needs and Service Plan. LPA's record review of the resident files revealed Resident One (R1) Physician Report on file was last dated on 03/25/2022. Licensee did not have an updated Physician's Report for R1. Residents diagnosed with Dementia must have an updated Physician's Report completed annually. A deficiency cited under Title 22 Regulation 87705(c)(5) Care of Persons with Dementia will be issued along with a plan of correction. Resident medication was centrally stored and locked in a cabinet in the dining room area. LPA reviewed medications for four (4) residents and found all medication listed on MARs and all required labeling was found to be in place. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items. Fire extinguishers were fully charged and inspected. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report, LIC 809-D, appeal rights, and technical assistance was provided to Licensee Ellery Jane.the state’s words, verbatim · CDSS document, Mar 18, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.