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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881239
Report Date: 07/29/2024
Date Signed: 07/29/2024 03:56:19 PM

Document Has Been Signed on 07/29/2024 03:56 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ELIAA LLC 2FACILITY NUMBER:
331881239
ADMINISTRATOR/
DIRECTOR:		YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:17520 BROWN STREETTELEPHONE:
(650) 656-7941
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 6CENSUS: 6DATE:
07/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Administrator, Amirra YouesTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Romero conducted a case management visit to issue a deficiency observed during LPA's visit at the facility on 7/29/2024.

On 7/29/2024, LPA toured the facility with Caregiver, Roger Valenzuela and observed two (2) refrigerators in the kitchen. The refrigerator next to the pantry was locked with a four (4) digit lock placed on the refrigerator doors. Resident interviews revealed the four (4) digit pin is not provided to the residents, making food in that refrigerator inaccessible to residents in care. LPA observed more than a 2-day supply of perishable foods in that refrigerator. Caregiver Valenzuela reported the refrigerator is locked because one (1) resident requires insulin pens that have to be refrigerated and inaccessible to all residents.

LPA advised Caregiver Valenzuela that it is a personal rights violation for residents to not have access to their food. Caregiver Valenzuela reported the second refrigerator had food accessible to the residents. LPA observed the second refrigerator (located next to the kitchen counter) did not have a 2-day supply of perishable foods for six (6) residents and instead had mostly condiments including four (4) tubs of butter. LPA also observed Caregiver Valenzuela use a key to unlock the pantry storing the 7-day supply of non-perishable foods for the residents. LPA inquired as to why the pantry was locked and Caregiver Valenzuela did not provide an explanation. LPA called Administrator, Amirra Younes and informed them of the deficiency observed. Administrator Younes reported they would have facility staff purchase a mini refrigerator for the insulin pens and remove the lock from the refrigerator and pantry during LPA's visit.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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 07/29/2024 03:56 PM - It Cannot Be Edited


Created By: Janette Romero On 07/29/2024 at 03:24 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: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
87468.1(a)(3)

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(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions... This requirement was not met as evidenced by:
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During LPA's visit on 7/29/2024, LPA observed Caregiver Valenzuela remove the lock from the refrigerator and unlock the pantry. This will suffice as proof of correction.
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During LPA's visit on 7/29/2024, LPA observed a four (4) digit lock placed on one of the refrigerator doors, which made the 2-day supply of perishable foods inaccessible to residents in care. LPA also observed the pantry to be locked. This poses a potential 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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ELIAA LLC 2
FACILITY NUMBER: 331881239
VISIT DATE: 07/29/2024
NARRATIVE
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During the visit, LPA observed House Manager, Ahmed Manassra arrive with a new mini refrigerator, which was installed in Administrator Younes' office. LPA observed Administrator Younes remove the insulin pens from the kitchen refrigerator and place them into the mini refrigerator stored in their office. LPA also observed Caregiver Valenzuela remove the lock on refrigerator and unlock the pantry. Based on the aforementioned, the facility will be cited pursuant to California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Younes along with LIC809-D and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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