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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602998
Report Date: 10/07/2024
Date Signed: 10/07/2024 07:37:34 PM

Document Has Been Signed on 10/07/2024 07:37 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELLEE RESIDENTIAL CARE #2FACILITY NUMBER:
197602998
ADMINISTRATOR/
DIRECTOR:		ELEANOR I POSNERFACILITY TYPE:
740
ADDRESS:11323 CALVERT STTELEPHONE:
(818) 980-6040
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Marte Galang, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Christine Yee, conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Maria Gregorio, Staff. Staff contacted Eleanor Posner, Administrator, via telephone to advise of LPA Yee's visit but she was not able to participate in today's visit due to family obligations until 5:30pm. Lee Posner, Co-Licensee arrived at 11:27am and Marte Galang arrived approximately at 12:30pm to conduct the visit. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms and 2 full bathrooms and a detached garage. Located in the back yard is a unfilled swimming pool currently secured by a wire fence. The facility is fire cleared for 6 NON-AMBULATORY residents.

The following domains were reviewed on today's visit: Staffing, Resident's Rights/Information and Planned Activities. Also reviewed on today's visit were 9 staff files and 5 resident files.

Per review of staff files the following were observed:
  • Licensee, Lee Posner does not have evidence of current first aid training
  • Staff, Michael Terok and Grace Rumiwang do not have a Health Screening (LIC503) on file
  • Staff, Maria Halili Gregorio does not have a signed Criminal Record Statement on file
  • Eleanor Posner and Marte Galang, Administrators do not have evidence of a current Administrator Certificate.
  • The facility does not have physicians orders on file for every medication that is centrally stored.
  • The facility does not have PRN Authorization letters on file for the residents PRN medications. Per the Administrator, Marte Galang, Staff do not contact the prescribing physician for instructions prior to administering the PRN medications and are making the decisions to dispense the medications themselves.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELLEE RESIDENTIAL CARE #2
FACILITY NUMBER: 197602998
VISIT DATE: 10/07/2024
NARRATIVE
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  • The facility does not main an inventory of residents valuables except for Resident #2
  • Resident #2 has an incomplete Physician's Report - no primary or secondary diagnosis is provided.
  • Admission Agreement for Residents #2 through Resident #5 do not state the rate for basic services. It just states "Tier 2" or "Tier 3" ALW Rate and Payment Provisions states: will be paid by ALW Program for basic service rate, cost for optional services, Payment is due: we will bill to ALW program every month.
  • Admission Agreement does not provide information about the Right to Resident Council or Family Council.
  • The Right to Resident Council or The Right to Family Council are not posted in the facility.
  • The Additional Personal Rights of Residents in Privately Operated Facilities is not posted.
  • The facility has internet access and no internet access device, such as a computer, laptop, Smart phone, tablet or other device that can support real time interactive application, is equipped with video conferencing technology, including a microphone and camera functions is dedicated for resident use.
  • the facility does not have a plan in place to permit residents shared access among all resident in the facility during reasonable hours.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 and Health and Safety Code, Chapter 3.2. Due to time constraints, any citations not addressed on today's visit, will be addressed on a return visit.

Exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2024 07:37 PM - It Cannot Be Edited


Created By: Christine Yee On 10/07/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELLEE RESIDENTIAL CARE #2
FACILITY NUMBER: 197602998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that the facility does not have completed LIC308s- Designation of Facility Responsiblity on file designating the authority and responsible staff to manage the facility when the Administrator is not present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care. The Administrator is on call during the day but not present at the facility until the evening.
POC Due Date: 10/14/2024
Plan of Correction
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The Licensee will complete LIC308 for every shift that the Administrator is not present at the facility and maintain in the respective staff's file for Department review when requested. Plan of correction to be completed and faxed to the Department by 10/14/24.
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above per interview with the Administrator and request for inservice training logs, facility was not able to provide evidence of intial and ongoing personal rights training for all members of its staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will ensure that all required initial training and ongoing training is provided to its staff. Evidence of all inservice training will be documented and maintained in the employees' file for review by the Department. The training logs should have the following information - date of the training, the subject of the training, hours of training, name of the instructor, address, telephone number, training materials. Submit evidence to the Department by 10/14/24
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 Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/07/2024 07:37 PM - It Cannot Be Edited


Created By: Christine Yee On 10/07/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELLEE RESIDENTIAL CARE #2
FACILITY NUMBER: 197602998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.157(f)(3)
Licensing
(3) If a facility does not have a resident council, upon admission, the facility shall provide written information on the resident’s right to form a resident council to the resident and the resident representative, as indicated in the admissions agreement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, the facility Admission Agreement does not address the resident's right to Resident Council which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will review the Admission Agreement and make updates to the Admission Agreement to include information about the right to create a Resident Councill. Licensee will also provide every current resident and their family with informaiton about the Right to Resident Council by 10/14/24.
Type B
Section Cited
HSC
1569.157(h)
Licensing
(h) The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the factiity, "Rights of Resident Council" was not observed posted anywhere in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will post "Rights of Resident Council" in a prominent location in the facility by 10/14/24.
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 Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/07/2024 07:37 PM - It Cannot Be Edited


Created By: Christine Yee On 10/07/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELLEE RESIDENTIAL CARE #2
FACILITY NUMBER: 197602998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.158(d)
Licensing
(d) A family council shall be provided with adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, per tour of the facility there was no bulletin board or other posting area for the display of meeting notices, information and news letters which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will ensure that if a family council is formed that adequate space is provided to hold meeting, posting of meeting notices, information and news letters by 10/14/24
Type B
Section Cited
HSC
1569.158(g)(2)
Licensing
(2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written information to the resident’s family members, friends, or resident representatives identified during the admission process of their right to form a family council.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of the Admission Agreement or documents there is no information provided to the resident or family about the right to create a family council which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will update the Admission Agreement to include information on creating a family council by 10/14/24.
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 Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/07/2024 07:37 PM - It Cannot Be Edited


Created By: Christine Yee On 10/07/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELLEE RESIDENTIAL CARE #2
FACILITY NUMBER: 197602998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, the facility has internet access and does not have a internet access device with videoconferencing, camera, microphone dedicated for resident use] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will provide residents with an internet access that meets Title 22 requirements noted above by 10/14/24.
Type B
Section Cited
HSC
1569.319(b)(1)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (1) The device shall be available in a manner that allows a resident to access it for discussion of personal or confidential information with a reasonable level of personal privacy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, per interview conducted, the facility does not have a internet access plan in place to allow a resident to access it for personal or confidential information with a reasonable level of priivacy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will put a internet access plan in place that will allow all residents to access the device within a reasonable time and with the ability to have personal privacy if needed. Provide the facility plan by 10/14/24.
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 Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/07/2024 07:37 PM - It Cannot Be Edited


Created By: Christine Yee On 10/07/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELLEE RESIDENTIAL CARE #2
FACILITY NUMBER: 197602998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(b)(2)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (2) The device shall be made available to residents in a manner that permits shared access among all residents in the facility during reasonable hours.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above the facility does not have a facility plan in place to allow residents to have shared access among all residents in the facility during reasonable hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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LIcensee will put together a plan that will allow all residents to use the internet access device during reasonable hours.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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 Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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