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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600661
Report Date: 04/24/2026
Date Signed: 04/24/2026 12:15:13 PM

Document Has Been Signed on 04/24/2026 12:15 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ELLE'S CARE HOMEFACILITY NUMBER:
415600661
ADMINISTRATOR/
DIRECTOR:		LASTIMOSA,KARINFACILITY TYPE:
740
ADDRESS:704 MADDUX DRIVETELEPHONE:
(650) 756-1351
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 4DATE:
04/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Caregiver, Arsenia Villadarez TIME VISIT/
INSPECTION COMPLETED:
12:37 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
On April 24, 2026, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Caregiver, Arsenia Villadarez and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are four resident rooms; two of which are single private rooms and two that are shared rooms. Resident rooms were observed to be clean with all required furniture. LPA observed 3/4 resident beds to have half bed rails. Two full bathrooms were observed to be clean, odor-free and in good repair. Water temperature throughout the facility measured between 123.6-129 degrees F. First aid kit was observed to be complete.

Dining room was observed free from tripping hazards. A comfortable temperature of 74 degrees F is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Medications, sharps, and chemicals were observed locked and inaccessible to residents in care. LPA observed all four residents' PM medication to be pre-poured into another container.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of
August 2025. Emergency drills are logged and done every 4 months. LPA reviewed 4 resident records and 4 staff records. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Caregiver and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
Document Has Been Signed on 04/24/2026 12:15 PM - It Cannot Be Edited


Created By: Komal Curley On 04/24/2026 at 11:20 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ELLE'S CARE HOME
FACILITY NUMBER: 415600661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPA observed chemicals located outside the facility unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2026
Plan of Correction
1
2
3
4
Licensee/administrator shall submit a photo of locked chemicals to LPA.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and resident files reviewed, 3/4 residents had half bed rails, however there were no physician's orders for the half bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2026
Plan of Correction
1
2
3
4
Licensee/administrator shall remove the half bed rails and provide LPA a photo. Licensee/administrator shall re-install half bed rails until physician's orders for the half bed rails are signed by each resident's physician. Licensee/administrator shall ensure all signed orders are maintained in resident files.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/24/2026 12:15 PM - It Cannot Be Edited


Created By: Komal Curley On 04/24/2026 at 11:20 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ELLE'S CARE HOME
FACILITY NUMBER: 415600661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the water temperature throughout the facility measured between 123.6-129 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
1
2
3
4
Licensee/administrator shall adjust water temperature so it's within regulatory requirements and send LPA photo proof.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on obserevations, all four residents' PM medication to be pre-poured into another container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
1
2
3
4
Licensee/administrator shall conduct an in-service training with all staff to stop pre-pouring of medications and to ensure medication is not being transferred between containers.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/24/2026 12:15 PM - It Cannot Be Edited


Created By: Komal Curley On 04/24/2026 at 11:20 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ELLE'S CARE HOME
FACILITY NUMBER: 415600661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on resident records reviewed, LPA observed 3/4 residents to not have service plans in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
1
2
3
4
Licensee/administrator shall complete service plans for the three residents and submit a copy to LPA by 5/1/26.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6