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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881239
Report Date: 12/27/2021
Date Signed: 12/28/2021 10:08:26 AM

Document Has Been Signed on 12/28/2021 10:08 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
RIVERSIDE, CA 92507
FACILITY NAME:ELIAA LLC 2FACILITY NUMBER:
331881239
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:17520 BROWN STREETTELEPHONE:
(650) 656-7941
CITY:PERRISSTATE: CAZIP CODE:
92507
CAPACITY: 6CENSUS: DATE:
12/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Amirra YounesTIME COMPLETED:
11:45 AM
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Please See Pre-Inspection For ElIAA LLC 2. Licensing Program Analyst (LPA) Venus Mixson met with Amirra and Ahmed, who showed LPA their CA drivers license to demonstrate that they were the same persons who completed component 1 and 2. LPA identified the purpose of the visit and requested a tour of the facility. The facility has four residential bed rooms that were numbered,each bedroom had a bed and night stand, as well as a chair for each residents use, and appropriate lighting. There was clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillow cases and pillows. There were extra bath towels and extra linen to permit changing at least once per week or more often if needed.There were nine smoke alarms/detectors that were all tested and in working order, as well as a locked placed for medications, the floors and all surfaces were clean and the facility was odorless. All window screens in bedrooms 1,3, and 4 were in good repair, the screen in bedroom number 2 was in need of repair, and will be replaced and repaired by days end. The licensee will send photo copies of the screen once replaced by days end. The faucets used by residents were tested and the temperature was not less than 105 and not more than 120 degrees. Grab Bars for each toilet, bathtub, and shower were being installed during this visit, the licensee will send photos of the grab bars by days end. There were non-skid mats in all bathtubs and showers. The laundry room had adequate supplies and space to sort soiled linen separate from clean. There were emergency lights such as flash lights and they were readily available. There were adequate hygiene items of general use such as soap and toilet paper. There was individual privacy provided in all toilet, bath, and shower areas.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2021
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 2
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
RIVERSIDE, CA 92507
FACILITY NAME: ELIAA LLC 2
FACILITY NUMBER: 331881239
VISIT DATE: 12/27/2021
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The premises was maintained in a state of good repair. There was a swimming pool that was fully surrounded by a locking gate. There was a fire place that had a screen cover. All outdoor and indoor passageways were clear of obstruction. There was adequate storage space for equipment and supplies. Disinfectants, and Cleaning solutions were kept locked in kitchen and the kitchen knives were locked as well as a enough plates, bowels and silverware for residents meals. There was a place to store medications with a lock and key, separately from other items. There was a first aid kit with adequate supplies. The facility had a working telephone and telephone service through Spectrum.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC809 (FAS) - (06/04)
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