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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881239
Report Date: 01/31/2023
Date Signed: 01/31/2023 04:36:12 PM

Document Has Been Signed on 01/31/2023 04:36 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
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:
92570
CAPACITY: 6CENSUS: 5DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Staff, Ahmed Qasin TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Janira Arreola and Jacqueline Shaw Ross conducted an unannounced visit to the facility in order to conduct an annual with a focus on infection control. LPA met with staff, Ahmed Qasin who was informed of the purpose of the visit. At the time of the visit there (3) staff and (5) residents present.

LPAs found that the facility has a central entry point in the facility entrance. The facility had hand sanitizer and face masks at the entry point. The staff took LPA's temperature upon entering. LPAs observed the facility's mitigation plan was not completed, and staff were not wearing their face mask at the time of the visit. Technical assistance notes were documented for COVID related guidance. LPA was also informed by staff that the facility does not have vaccine information for (1) staff member. This will be address along with items below.

LPAs conducted a tour of the interior and exterior of the facility. The following was found to be out of compliance with the California Code of Regulations Title 22 Division 6 Chapter 8:
  • LPAs observed the following concerns with staff. LPAs rang the door bell the the home and had staff answer the door who claimed not hearing the door bell ring, and a facility resident was the one who answered the door for the LPAs. When LPAs asked what population the facility served, the staff was unable to answer the question. A staff member reported sleeping on the floor of the staff room, and when LPA asked the staff manger they stated the master bedroom (bedroom #1) was for staff. Room #1 was observed to have mattresses with no bed linens.
  • LPA observed cleaners in the laundry room, in the facility garage, under sink in staff bathroom, and staff master bedroom that were being kept unlocked.
  • LPA observed unlocked injectable insulin syringes in the resident refrigerator.
  • LPAs observed the drawer where knifes and sharp objects are to be stored had a lock that was not functioning properly. Therefore, leaving the knifes accessible to residents.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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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: 01/31/2023
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  • LPAs found that the perishable and non-perishable foods did not meet the department requirements of 2-day and 7-day supplies.
  • LPA observed the facility was in disrepair with door bell that was taped to the wall, door knob for medications closet that was taped shut to the door, and the lock for the sharp objects that was lose. LPA also observed the facility fence in the backyard was in disrepair with a gap between pieces of wood and damaged chain link fence.
  • LPAs also observed the facility was not in clean and sanitary condition with bottles of empty beverages in the facility front yard, cans of cigarette butts found in the facility back yard, front yard, and staff office. LPAs also found the restroom in bedroom #1 to have shower floor with debris, and stained carpet. The front yard and back yard had over grown weeds and was filled with tumble weeds. The pool was filled half way with water that was green in color and appeared to not be maintained regularly. Staff reported that after it rained the pool had not been cleaned. LPAs also noticed a hole in the wall of the medicine closet.
  • LPAs found personal rights concerns with observed infant diapers in the facility storage room. Staff informed LPA that these were being used for a resident that had moved out of the facility "7" months ago. Staff also stated that residents use shared personal hygiene items in the resident bathroom. LPAs observed these hygiene items were not labeled with resident names. Resident rooms #3 and #4 were observed to be missing dresser space for the resident, as well as bed linens, and chair. With resident in room #3 stating they kept their clothing in trash bags. LPAs also observed the "dinning area" was comprised of a fold out table with (3) chairs.

Due to time constraints, the above observation will be cited and discuss on Friday February 3,2023 at the regional office with facility administrator Amirra Younes at 9:00am.

An exit interview was conducted where this report was reviewed and provided to staff, Ahmed Qasim.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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