Elle's Care Home 2

Type of visit: Required - 1 Year

On 09/16/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required 1 year inspection visit. LPA met with caregiver Leah Slavador and explained the purpose of today's visit. There are currently 3 staff present and 5 residents in care. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory and one bedridden. License is approved for 3 hospice residents. There is 1 resident on hospice as of this visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site. LPA observed the facility kitchen which is observed as in good working condition. Knives are stored and locked in a drawer adjacent to the sink. There is a locked cabinet beneath the kitchen sink but no cleaning supplies are present when observed. Perishable and non-perishable food supplies are observed as in place. There is an additional cabinet in the garage which stores additional canned goods and dry goods for resident and staff use. First aid kit is observed as complete with required items stored in the medication cabinet which is observed to be locked. LPA observed at least two fire extinguishers in place which are currently within operating range, combination smoke/carbon monoxide detectors are observed in place through out the facility, and central heating. A carbon monoxide detector in place located in a hallway was tested but it did not work. This is a repeat from the 2024 inspection and poses a potential health and safety risk. The facility had combination carbon monoxide/smoke detectors in place that did work according to staff. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA made observations of the exterior and observed items stored beneath the raised wooden walkway such as old bed frames, trash bags filled with items, walkers, bed cushion, plastic drawers and shelves. The raised wooden walkway is considered as part of the emergency exit route and a bedframe is observed on this walkway leaned against the wall and there is a hole in one of the boards posing an immediate health and safety risk to staff and residents in care in the event of an emergency. Continued on next... Page 2 Along the north side of the facility LPA observed unused washer and dryer, postural equipment, box of clothing/shoes, unused bicycle covered heavily with spider webs, and unlocked paint cans are observed, crawl space screen is also observed as missing and it large hole. The paint cans pose an immediate health and safety risk to residents in care. Water temperature was measured in a resident bathroom at 120F. Cleaning supplies are observed to be locked in the garage primarily. LPA did observe several items as not in good repair during the inspection such as: broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility which was also expired as of 08/05/2013, bathroom sink does not fully drain but a plumber is coming to repair the clogged drain but the sink does work. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Linen closet is observed as stocked with such items for resident use. Shower floors are equipped with non-skid mats or flooring as observed. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 5 resident files and 3 staff files. LPA observed that S1 was not associated and did not have a finger print clearance on file with department and does not have a TB clearance that can be reviewed. This poses and immediate health and safety risk to residents in care. Administrator certificate is current expiring 07/06/2026. The following updated forms are requested to be submitted to CCLD by 09/23/2025: • Copy of administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC402 Surety bond information with expiration date • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule Citations are issued on this day on the attached LIC809D pages. Civil penalties are assessed during today's visit attached to this report. $100 x 2 citations = $200 and $1000 x 2 repeat citations = $2000. Report is reviewed with caregiver Leah Salvador and a copy is provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 17, 2025

87355(e)(2) Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This regulation has not been met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 is not associated to the facility on this day. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: The facility shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Immediate civil penalty of $100 for S1 is being assessed on this day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Sep 17, 2025

87355(e)(1) Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by: Based on records review, licensee failed to obtain a criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 does not have a criminal record clearance on this day per department review. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Administrator shall ensure to submit proof of fingerprinting of S1 and proof of clearance to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Immediate civil penalty of $100 for S1 is being assessed on this day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 17, 2025

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidenced by: Based on facility observations made, LPA observed broken door alarm for sliding door, broken carbon monoxide detector in the front hallway, a hole in the floor of the wooden passageway that is used as an emergency exit route, a missing/broken screen that leads to the crawlspace beneath the facilitythe state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee shall submit a plan of correction in writing showing how the facility will maintain the facility in good repair at all times. Civil penalty issued for a repeat violation wihtin a 12 month period.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Sep 17, 2025

87309(a) Storage Space -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. Based on facility observations made, LPA observed observed paint cans unsecured outside of the facility alone the north side exterior pathway. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee shall submit a plan of correction in writing showing how the facility will store paint and other items that could pose a danger to residents in care. Civil penalty issued for a repeat violation wihtin a 12 month period.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Sep 17, 2025

87307(d)(6) Personal Accommodations and Services - The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This regulation has not been met as evidenced by: Based on facility observations made, LPA observed the north side exterior passageway of the facility contains several items causing the passageway to be very narrow due to it storing items that are in need to be disposed of such as old washer and dryer, postural equipment, box of clothing/shoes, old bicycle, unsused water jugs, and other items. Additonally the wooden raised passageway used as an emergency exit route has an old bedframe on the passageway leaning against the wall. This passageway is used as part of the emergency exit route.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee shall submit a plan of correction in writing showing how the facility will maintain this regulation at all times.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Sep 19, 2025

87412(a) Personnel Records - The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This regulation has not been met as evidenced by: Based on staff files reviewed, S1 does not have a complete file to review. The only items observed are the first aid card and health screening.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee shall submit a plan of correction in writing showing how the facility will maintain current and up to date records at all times and complete the file for S1.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 17, 2025

87468.1(a)(2) Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulation has not been met as evidenced by: Based on staff files reviewed, S1 did not receive, and does not have a record, of receiving a TB test prior to working at the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee shall submit a plan of correction in writing showing how the facility will maintain this regulation at all times and obtain TB testing and clearance for S1.

Type of visit: Required - 1 Year

On 09/25/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required 1 year inspection visit. LPA met with caregiver Jeremiah Slavador and explained the purpose of today's visit. There are 2 staff present and 4 residents in the facility. According to staff there are 3 GGRC residents and 1 RCFE resident. Around 245pm the licensee met with LPA Vado at the facility. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory and one bedridden. License is approved for 3 hospice residents. There are no residents on hospice as of this visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregiver. LPA observed the facility kitchen which is observed as in good working condition. Knives are stored and locked in a drawer adjacent to the sink. There is a locked cabinet beneath the kitchen sink but no cleaning supplies are present when observed. Perishable and non-perishable food supplies are observed as in place. There is an additional cabinet in the garage which stores additional canned goods and dry goods for resident and staff use. First aid kit is observed as complete with required items stored in the medication cabinet which is observed to be locked. LPA observed at least two fire extinguishers in place which are currently within operating range, combination smoke/carbon monoxide detectors are observed in place through out the facility, and central heating. A carbon monoxide detector in place located in a hallway was tested but it did not work. The facility had combination carbon monoxide/smoke detectors in place that did work. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA made observations of the exterior and observed items stored beneath the raised wooden walkway such as old bed frames, screen doors, a shopping cart, and old wheel chairs. Additionally LPA observed unlocked paint cans stored beneath the walkway. The paint cans pose an immediate health and safety risk to residents in care. Water temperature was measured in a resident bathroom at 122F and increasing during testing which poses as a health and safety issue for residents in care. In this same bathroom LPA observed cleaning solutions stored beneath the bathroom sink which poses an immediate health and safety risk to residents in care. Cleaning supplies are observed to be locked in the garage primarily. Continued on next... Page 2 LPA did observe several items as not in good repair during the inspection such as: torn or missing window screens on resident windows, broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility, and a broken grab bar that is under repair per staff interview which can poses as a health and safety risk to residents in care. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Linen closet is observed as stocked with such items for resident use. Shower floors are equipped with non-skid mats or flooring as observed. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed four resident files and three staff files. Administrator certificate is expired as of 07/06/2024 but according to the administrator/licensee she has already renewed and is pending per administrator certification branch. The following updated forms are requested to be submitted to CCLD by 09/30/2024: • Copy of administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC400 Affidavit regarding client/resident cash resources • LIC402 Surety bond information with expiration date • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease Citations are issued on this day on the attached LIC809D pages. Report is reviewed with licensee Karin Lastimosa and a copy is provided.the state’s words, verbatim · CDSS document, Sep 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 26, 2024

87309(a)Storage Space -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. Based on facility observations made, LPA observed cleaning supplies stored beneath a resident bathroom sink unsecured. LPA also observed paint cans being stored beneath the raised wooden walkway located at the side of the facility and a can located near the side gate. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Can are removed by staff person Jeremiah during today's visit. *** THIS POC IS CLEARED AND CORECTED DURING TODAY'S VISIT ***

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(e)(2) · Plan of correction due date: Sep 26, 2024

87303(e)(2) MAINTENANCE AND OPERATION - Water supplies and plumbing fixtures shall be maintained as follows: 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 degree C) and not more than 120 degree F (49 degree C).This regulation has not been met as evidenced by: Based on faciltiy observations made, LPA tested the water in a common resident bathroom in a hallway at the front of the facility. Water temperature was measured at 122F and increasing during today's visit. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Licensee shall submit a plan of correction on how the facility will maintain water temperatures between 105F and not more than 120F in faucets used by residents for personal care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 30, 2024

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidenced by: Based on observations made, LPA observed that torn or missing window screens on resident windows, broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility, and a broken grab bar that is under repair per staff interview.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Licensee shall submit a plan of correction in writing showing how the facility will maintain the facility in good repair at all times.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(c) · Plan of correction due date: Sep 30, 2024

87303(c) Maintenance and operation - All window screens shall be clean and maintained in good repair. This regulation has not been met as evidenced by: Based on observations made, LPA observed that several window screen through out the faciltiy are either damaged, ripped, or not in place. This posese a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Licensee shall submit a plan of correction showing all window screens that are not in good repair have been replaced and how the faciltiy will maintain them in good repair at all times.