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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881239
Report Date: 02/03/2023
Date Signed: 02/03/2023 09:44:33 AM

Document Has Been Signed on 02/03/2023 09:44 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:
92570
CAPACITY: 6CENSUS: 5DATE:
02/03/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensees Ahmed Qasin and Amiraa YounesTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manager (LPM) Joel Esquivel conducted an informal office meeting with Ahmed Qasin and Amiraa Younes, owners of Eliaa LLC 2. The purpose of the meeting was to discuss deficiencies observed during an annual visit on 1/31/2023.

The following topics were discussed under the California Code of Regulations Title 22 Division 6 Chapter 8:
  • 87303 Maintenance and Operation
  • 87465 Incidental Medical and Dental Care
  • 87309 Storage Space
  • 87468.1 Personal Rights of Residents in All Facilities
  • 87555 General Food Service Requirements

Deficiencies noted on 1/31/2023 were cited today and are detailed on LIC 809-D pages.

The Technical Support Program (TSP) was offered to the licensees. The department will make a referral for the facility.

A copy of this report, LIC 809-D pages, and appeal rights were provided to Licensees Ahmed Qasin and Amiraa Younes during the exit interview.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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 02/03/2023 09:44 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/02/2023 at 10:13 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELIAA LLC 2
FACILITY NUMBER: 331881239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place...
This requirment was not met as evidenced:
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Licensee stated they will keep the medications in a locked refrigerator. The Licensee shall conduct staff training on proper storage of residents medications. The training material and signed staff roster shall be submitted by POC due date to LPA.
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Based on observation and interview it was found that resident's insulin was being kept in the facility fridge unlocked. This poses an immediate health, saftey, or persoanl rights risk.
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Type A
02/04/2023
Section Cited
CCR87309(a)(1)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons... and other items which could pose a danger... shall be stored where inaccessible to clients. (1) Storage areas for poisons... shall be locked.
This requirment was not met as evidenced by:
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Licensee stated they will designated a stroage box in a locked staff room that will house the facility knifes. The licensee will also conduct training with staff on proper storage of dangerous items. The training material shall be sent to the LPA by POC due date with signed roster of staff.
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Based on interview and observation LPA found multiple cleaning products that were being kept, as well as the sharp objects. This poses an immediate health, saftey or personal rights risk.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


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Document Has Been Signed on 02/03/2023 09:44 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/02/2023 at 09:36 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELIAA LLC 2
FACILITY NUMBER: 331881239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
97303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...
This requirment was not met as evidenced by:
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Licensee stated they will send the LPA photos of items observed during the visit on 1/31/2023 to LPA by the POC due date of repiars that have been completed.
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Based on LPA observation and interviews, it was found that facility had multiple items that needed repairing and cleaning. This poses a potential health, saftey or 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


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Document Has Been Signed on 02/03/2023 09:44 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/02/2023 at 10:31 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELIAA LLC 2
FACILITY NUMBER: 331881239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
97468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships... This requirment was not met as evidenced by:
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Licensee stated they will discontinued the pratice from their facility. The licensee stated this during the meeting.
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Based on LPA observation and interview, it was found that the facility had been using infant diapers on the residents. This poses an immdeiate health, saftey or personal rights risk to residents in care.
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Type A
02/04/2023
Section Cited
CCR8468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded... comfortable accommodations, furnishings and equipment. This requirment was not met as evidenced by:
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The licensee stated they will have appropriate accomidations for the residents in their bedrooms. The licensee will send photos to the LPA of correction by POC due date.
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Based on observation and interview it was found that facility furniture in bedrooms #3 and #4, dining area, and staff room did not poses the required furnture to meet residents needs. This poses an immediate health, saftey or personal rights risk.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


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Document Has Been Signed on 02/03/2023 09:44 AM - It Cannot Be Edited


Created By: Janira Arreola On 02/02/2023 at 10:52 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELIAA LLC 2
FACILITY NUMBER: 331881239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirment was not met as evidenced by:
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Licensee stated they will have the required stock of required food items at the facility at all times. The Licensee shall send photos to LPA showing the food supply meets this requirement by the POC due date.
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Based on observation and interview it was found that the facility food supply did not meet the 2-day and 7-day requirments and residents were storing personal snacks in their bedrooms. This poses an immediate health, saftey or personal rights risk.
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Type A
02/04/2023
Section Cited
CCR87628(a)

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87628 Diabetes (a)The licensee shall be permitted to accept...a resident who has diabetes if the resident is able to perform his/her own glucose testing...and is able to administer his/her own medication including medication...or has it administered by...skilled professional.
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Licensee stated that they will discontinue the practice and have residents with diabetes administer and manage their injections and readings. This was stated during the meeting.
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This requirment was not met as evidenced by: Based on interview iwith adminsirtator it was found that the untrained staff are assisting the residents with glucose reading and sliding scale for residents with diabetes.This poses an immidate personal rights, health or saftey risk for residents.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


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