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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881116
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:21:08 AM

Document Has Been Signed on 02/09/2023 11:21 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ELIAA, LLCFACILITY NUMBER:
331881116
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:11545 DOVERWOOD DR.,TELEPHONE:
(650) 656-7941
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 6CENSUS: 6DATE:
02/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Licensee/Administrator Ahmed QasimTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/09/2023 at 9:05 AM and met with Licensee/Administrator Ahmed Qasim to initiate a Case Management Visit. LPA Brown explained the purpose of the visit. The investigation consisted of interviews and a review of pertinent documentation.

On 02/09/2023, LPA Brown received Personnel Report Summary (LIC500) from Licensee/Administrator Ahmed Qasim. LPA Brown observed per records review that Staff # 6 (S6) was listed in LIC500 with date hire date 11/15/2022 but without criminal background clearance and S6 confirmed to LPA Brown that S6 started working at the facility 11/15/2022. During the facility visit on 02/09/2023, Licensee/Administrator Qasim confirmed that S6 started working at the facility 11/15/2022. LPA Brown observed per records review that S6 does not have criminal background clearance per Guardian website and the facility allowed S6 to work at the facility since 11/15/2022. LPA Brown will issue a deficiency as this pose immediate health, safety and personal rights risk to residents in care.

Civil penalty was assessed with the amount of $500.00 during the visit for S6 working at the facility without Criminal Background Clearance.

An exit interview was conducted with Licensee/Administrator Ahmed Qasim where a copy of this report (LIC 809) along with LIC 809D, LIC421BG and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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Document Has Been Signed on 02/09/2023 11:21 AM - It Cannot Be Edited


Created By: Melody Brown On 02/09/2023 at 10:54 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
87355(e)(1)

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87355 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...(1) Obtain a California clearance...This requirement is not met as evidenced by:
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Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date.
Licensee stated to remove S6 from the facility and not allow S6 to work at the facility until S6 have a criminal background clearance.
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Based on interview and records review, the Licensee did not comply with the section cited above by allowing S6 to work at the facility without criminal background clearance which pose immediate health, safety and personal rights risk to residents in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
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