<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881116
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:59:21 PM

Document Has Been Signed on 03/10/2023 12:59 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
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: 7DATE:
03/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Ahmed QasimTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 03/10/2023 at 09:00 AM to commence a health and safety check. LPA Brown identified herself and discussed the purpose of the visit with Licensee/Administrator Ahmed Qasim due to complaint 56-AS-20230308123000.

Seven (7) residents in care were present during the visit. No imminent health and/or safety concerns observed at the time of visit. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Brown inspected facility food supplies and observed more than three (3) days’ supply of perishable and more than seven (7) days’ supply of non-perishable food. The needs of the residents in care appear to be met during this inspection.

LPA Brown observed one (1) staff present at the facility to provide care. During the visit, LPA Brown observed Staff # 6 (S6) living at the adjacent two-storey building located at the back of the facility compound without criminal background clearance. LPA Brown explained to Licensee/Administrator Ahmed Qasim that the facility was cited for the same deficiency for staff working at the facility without criminal background clearance last 02/09/2023. Civil Penalty was assessed for repeat violation on Criminal Background Clearance within a 12-month period with the amount of $3.000.00 and will continue to be assessed of $100.00 per day per citation until corrected during the facility visit due to the facility continuedly allowed S6 to stay and live at the adjacent two- storey building located at the back of the facility compound without criminal background clearance since 02/09/2023.

Moreover, during the tour of the facility, LPA Brown discovered that there are seven (7) residents residing at the facility. LPA Brown interviewed Resident #7 (R7) and R7 reported that two (2) other residents, Resident #9 (R9) and Resident #10 (R10) are living at the adjacent two-storey building located at the back of the facility. This facility is licensed for six (6) clients. *** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 03/10/2023 12:59 PM - It Cannot Be Edited


Created By: Melody Brown On 03/10/2023 at 10:27 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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/11/2023
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
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 living at the the adjacent two- storey building located at the back of the facility compound and not allow S6 to work at the facility until S6 has a criminal background clearance.
8
9
10
11
12
13
14
Based on interview and records review, the Licensee did not comply with the section cited above by continuedly allowing Staff #6 to stay and live at the adjacent two- storey building located at the back of the facility compound without criminal background clearance since 02/09/2023 which pose immediate health, safety and personal rights risk to residents ion care.
8
9
10
11
12
13
14
Deficiency Dismissed
Type A
03/11/2023
Section Cited
CCR80020(a)

1
2
3
4
5
6
7
80020. Fire Clearance. (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee has agreed to read regulation 80020 entirely and send LPA self-certified letter that the regulation was read and understood. The licensee has agreed provide care for a maximum of six (6)residents and follow the limitations specified in their license. POC is due by 03/11/2023.
8
9
10
11
12
13
14
Based on interview, observation, and record review, the licensee did not comply with the section cited above by having seven (7) residents at the facility which is beyond the conditions and limitations specified in their license which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116
VISIT DATE: 03/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 LPA Brown explained to Licensee/Administrator Qasim that it is a violation of the approved fire clearance and poses an immediate risk to the residents in care. An Immediate Civil Penalty was assessed during the visit with the amount of $500.00. LPA Brown will issue a deficiency for this issue as this pose immediate health, safety and personal rights risks to residents in care.

An exit interview was conducted where this report, LIC809, along with LIC809D, LICC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Ahmed Qasim..
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3