Elsa Care Home

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegations. LPA met with Administrator Kennedy Wainaina Complaint alleges personal rights violation. Complainant states that staff (S1) yell at and intimidate R1, that R1 is afraid of S1, and that staff have threatened R1 with eviction. During investigation, LPA received conflicting accounts of staff yelling at R1. LPA conducted interview with R1. R1 indicated to LPA that staff have not threatened them with eviction. R1 advised LPA they are not afraid of S1. During investigation, LPA interviewed facility licensee and Administrator, both of whom denied issuing R1 a notice of eviction. During investigation, LPA also interviewed staff. Four (4) out of four (4) staff report that R1 has not been threatened with eviction and that S1 does not yell at R1. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 2, 2026 · control 21-AS-20260603093046

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrators Alfonso Galvez and Kennedy Wainaina arrived later. Kennedy Wainaina Administrator Certificate 7025718740 expired 6/9/27. Facility currently has six (6) residents in care, one (1) of which is currently on hospice. At approximately 12:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. LPA observed kitchen cabinet under sink to contain disinfectants and cleaning supplies. Cabinet has magnetic locking mechanism, one side of which was malfunctioning. Per Admin, they will replace lock immediately. While LPA present, licensee arrived with new locks. All other cleaning products and laundry soaps are located in the garage and inaccessible to residents in care. LPA and Admins discussed ensuring all creams and hygiene products that have an active ingredient and a warning label should be inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 107.3 degrees F in the kitchen which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 01/30/26. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 2/1/26. Facility has a backup generator for use during a power outage. Continued on 809C... Continued for 809... At approximately 1:00pm LPA conducted a review of six (6) out of six (6) resident files. No deficiencies cited. LPA discussed with Admin Video Surveillance disclosure forms. LPA discussed disclosure form is being signed by the resident themselves. LPA advised that the responsible party should be acknowledging the disclosure. LPA advised any time facility has a resident that will be bedridden for longer than 14 days, facility must notify the local fire department to advised of bedridden status. Facility does not have bedridden fire clearance. Admin filled out notification form and sent to fire department while LPA present. At approximately 2:00pm LPA conducted a review of five (5) out of five (5) staff files. No deficiencies cited. At approximately 3:00pm LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. The following medications had counts that were off based on the start date and dosage required: Finasteride 5mg date started was 5/20/26. Bubble pack had 31 tabs, one tab per day was supposed to be given but 18 tabs remain. Losartan 50mg date started was 5/12. Bubble pack had 31 tabs but 2 remain. Pantoprazole 20mg was started 5/12/26. Bubble pack had 31 pills but 4 pills remain (deficiency cited, see 809D). Additionally, while doing the med count LPA and licensee found that medications are being pre-poured which is why some other counts were off (deficiency cited, see 809D). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 8, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff member does not adequately supervise resident in care.

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegations. LPA met with Administrator Kennedy Wainaina. Complaint alleges staff member does not adequately supervise resident in care. Resident (R2) has recently started attending a day program. The program has a hand-to-hand escort policy. This policy requires that all participants are escorted in and their escort must wait while the participant’s temperature is taken and the participant has a quick assessment to establish they are presenting as well enough to attend that day’s program. This policy is communicated verbally and through email. LPA confirmed that email notifying staff of the policy was provided to the facility staff responsible for the transport of R2 to the day program. Evidence obtained during investigation indicates that the staff transporting R2 was not following the hand-to-hand escort policy; instead the staff would drop off R2, without escorting them into the Continued on 9099C... Substantiated Continued from 9099... building, and would drive off before R2 had their temperature taken resulting in at least one instance where the staff had to return to the program and pick up resident because they had a high temperature. Witness reports that staff was also not following the hand-to-hand escort practice when picking up R2 from the program. LPA’s review of R2’s physician report indicated that R2 cannot leave the facility unassisted. LPA‘s review of R2’s care plan indicated that R2 requires support and guidance in organizing tasks such as public transportation. Staff did not ensure adequate supervision of R2 by not following the hand-to-hand escort policy. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 22, 2025 · control 21-AS-20250923110324

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 24, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in care...shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: staff did not adequately supervise R2, which poses an potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: Staff will utlize drop off and pick up sign-in sheet every day during dropping off and picking up resident from day program. Staff will provide signature of drop off and pick up showing that they are escorting the resident in and out of the day program facility. Facility will submit logs from time period of 10/27/25 through 12/1/25. Facility will send plan to submit logs by plan of correction due date. Logs due to CCL on 12/5/25

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a pre-licensing inspection and was greeted by caregiver. LPA contacted licensee Victoria Wainaina to advise LPA here to complete Pre-licensing inspection. Facility Administrator, Kennedy Wainaina arrived later. Facility currently has four [4] residents in care. LPA reviewed staff roster. LPA and Admin transferred all current staff from facility Elsa's Home 496803960 to Elsa Care Home 496804279. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA observed within regulation emergency supply of non-perishable food. Garage stores two [2] overflow food refrigerators. Garage has locked metal cabinet that stores toxins and cleaning products. One locked drawer in kitchen is dedicated for sharp knives. Cleaning products under kitchen sink locked. Facility is a one story residence with seven [7] bedrooms, one of which is a dedicated staff room, rooms one [1] and two [2] have a jack and jill style shared bath and room six [6] has a private half bath. Facility has two full bathrooms, dining and living room common areas, and a front sitting area used primarily for facility office administration. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has central air and a back up generator. Present in the dining room is a ring camera. LPA asked Admin if there was a resident notification signed and on file, disclosing the video camera. Admin will provide disclosure notification to LPA before license is issued. Continued on 809C... Continued from 809... Water temperatures read at: 105.2 F in kitchen, 108.3 F in main bath, and 107.5 in full bath next to rooms five and six, all of which are within regulation of 105 & 120 degrees F. Smoke and carbon monoxide detectors present and functioning, last serviced by vendor January 2025. Facility has fire extinguishers present and charged, last serviced 2/10/25. Emergency lighting lanterns present in living room. LPA observed all required postings and posters present. Facility is currently and actively replacing left hand side of perimeter fence. LPA spoke to construction team and inquired as to portion of fence in the very front portion of the right hand side of the facility. Construction person indicated that currently, it is not scheduled to be replaced. LPA discussed with Admin that this portion of the fence will also need to be replaced in addition to the portion of the fence currently being replaced. Construction person informed LPA that estimated completion date of the fence should be by this Saturday, May 24, 2025. LPA showed Admin what appeared to be dry rot on bottom portion of front deck and some loose boards. LPA advised Admin to keep an eye on the stability of the deck structure and to replace once stability is no longer secure. Admin agreed and will have deck replaced/repaired if/when structure becomes unstable. LPA reviewed facility sketch. Sketch found to be accurate and depicts location of water, gas, and electrical shut offs as well as location of smoke and carbon monoxide detectors. LPA reviewed staff and resident files. The following items to be corrected prior to LPA submission of facility's application for approval: Training for all staff to meet hours requirement per regulation HSC1569.625(b), all staff must complete an additional 4 hours of dementia training with the following exceptions: S3 needs to complete annual continuation of training in the amount of 20 hours per HSC1569.625(b)(2) and S4 must complete 15 hours of training, six of which must be on dementia care. Additionally, S1, S2, and S4 need current 1st Aid/CPR and S1 needs a Health Screen (TB clearance is present and on file). Continued on 809C(2)... Continued from 809C... The following items to be corrected prior to LPA submission of facility's application for approval: Repair two loose boards on right hand side of backyard fence Screen to sliding glass door torn and cut in multiple places Street-facing front right hand side portion of fence to be replaced Signed resident notification of disclosure of camera in living room All staff must complete an additional 4 hours of dementia training with the following exceptions: S3 needs to complete annual continuation of training in the amount of 20 hours per HSC1569.625(b)(2) and S4 must complete 15 hours of training, six of which must be on dementia care. S1, S2, and S4 need current 1st Aid/CPR S1 needs a Health Screen (TB clearance is present and on file). Administrator to provide photos and/or videos of repaired/replaced items. Once acceptable photographic and/or video proof of corrections is received by CCL, LPA will submit facility's application for approval. Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.the state’s words, verbatim · CDSS document, May 22, 2025