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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600763
Report Date: 09/16/2025
Date Signed: 09/16/2025 01:47:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/16/2025 01:47 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 HOME 2FACILITY NUMBER:
415600763
ADMINISTRATOR/
DIRECTOR:		LASTIMOSA, KARIN S.FACILITY TYPE:
740
ADDRESS:18 ROSALITA LANETELEPHONE:
(650) 872-1389
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver - Leah SalvadorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 09/16/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required 1 year inspection visit. LPA met with caregiver Leah Slavador and explained the purpose of today's visit. There are currently 3 staff present and 5 residents in care.

This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory and one bedridden. License is approved for 3 hospice residents. There is 1 resident on hospice as of this visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site. LPA observed the facility kitchen which is observed as in good working condition. Knives are stored and locked in a drawer adjacent to the sink. There is a locked cabinet beneath the kitchen sink but no cleaning supplies are present when observed. Perishable and non-perishable food supplies are observed as in place. There is an additional cabinet in the garage which stores additional canned goods and dry goods for resident and staff use. First aid kit is observed as complete with required items stored in the medication cabinet which is observed to be locked. LPA observed at least two fire extinguishers in place which are currently within operating range, combination smoke/carbon monoxide detectors are observed in place through out the facility, and central heating. A carbon monoxide detector in place located in a hallway was tested but it did not work. This is a repeat from the 2024 inspection and poses a potential health and safety risk. The facility had combination carbon monoxide/smoke detectors in place that did work according to staff. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA made observations of the exterior and observed items stored beneath the raised wooden walkway such as old bed frames, trash bags filled with items, walkers, bed cushion, plastic drawers and shelves. The raised wooden walkway is considered as part of the emergency exit route and a bedframe is observed on this walkway leaned against the wall and there is a hole in one of the boards posing an immediate health and safety risk to staff and residents in care in the event of an emergency.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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 7
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)
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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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ELLE'S CARE HOME 2
FACILITY NUMBER: 415600763
VISIT DATE: 09/16/2025
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Along the north side of the facility LPA observed unused washer and dryer, postural equipment, box of clothing/shoes, unused bicycle covered heavily with spider webs, and unlocked paint cans are observed, crawl space screen is also observed as missing and it large hole. The paint cans pose an immediate health and safety risk to residents in care. Water temperature was measured in a resident bathroom at 120F. Cleaning supplies are observed to be locked in the garage primarily. LPA did observe several items as not in good repair during the inspection such as: broken carbon monoxide detector did not function when tested in the hallway central to resident room towards the front of the facility which was also expired as of 08/05/2013, bathroom sink does not fully drain but a plumber is coming to repair the clogged drain but the sink does work. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Linen closet is observed as stocked with such items for resident use. Shower floors are equipped with non-skid mats or flooring as observed. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 5 resident files and 3 staff files. LPA observed that S1 was not associated and did not have a finger print clearance on file with department and does not have a TB clearance that can be reviewed. This poses and immediate health and safety risk to residents in care. Administrator certificate is current expiring 07/06/2026.

The following updated forms are requested to be submitted to CCLD by 09/23/2025:

• Copy of administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC402 Surety bond information with expiration date
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule

Citations are issued on this day on the attached LIC809D pages. Civil penalties are assessed during today's visit attached to this report. $100 x 2 citations = $200 and $1000 x 2 repeat citations = $2000.

Report is reviewed with caregiver Leah Salvador and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/16/2025 01:47 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/16/2025 at 11:14 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 2
FACILITY NUMBER: 415600763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2025
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This regulation has not been met as evidenced by:
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The facility shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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Based on records review, licensee failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 is not associated to the facility on this day. This poses an immediate health and safety risk to residents in care.
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Immediate civil penalty of $100 for S1 is being assessed on this day.
Type A
09/17/2025
Section Cited
CCR87355(e)(1)

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87355(e)(1) Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator shall ensure to submit proof of fingerprinting of S1 and proof of clearance to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement was not met as evidenced by: Based on records review, licensee failed to obtain a criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 does not have a criminal record clearance on this day per department review. This poses an immediate health and safety risk to residents in care.
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Immediate civil penalty of $100 for S1 is being assessed on this day.
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:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/16/2025 01:47 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/16/2025 at 11:27 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 2
FACILITY NUMBER: 415600763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2025
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidenced by:
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Licensee shall submit a plan of correction in writing showing how the facility will maintain the facility in good repair at all times.
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Based on facility observations made, LPA observed broken door alarm for sliding door, broken carbon monoxide detector in the front hallway, a hole in the floor of the wooden passageway that is used as an emergency exit route, a missing/broken screen that leads to the crawlspace beneath the facility
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Civil penalty issued for a repeat violation wihtin a 12 month period.
Type A
09/17/2025
Section Cited
CCR87309(a)

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87309(a) Storage Space -Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Licensee shall submit a plan of correction in writing showing how the facility will store paint and other items that could pose a danger to residents in care.
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Based on facility observations made, LPA observed observed paint cans unsecured outside of the facility alone the north side exterior pathway. This poses an immediate health and safety risk to residents in care.
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Civil penalty issued for a repeat violation wihtin a 12 month period.
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:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/16/2025 01:47 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/16/2025 at 11:40 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 2
FACILITY NUMBER: 415600763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2025
Section Cited
CCR
87307(d)(6)

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87307(d)(6) Personal Accommodations and Services - The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This regulation has not been met as evidenced by:
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Licensee shall submit a plan of correction in writing showing how the facility will maintain this regulation at all times.
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Based on facility observations made, LPA observed the north side exterior passageway of the facility contains several items causing the passageway to be very narrow due to it storing items that are in need to be disposed of such as old washer and dryer, postural equipment, box of clothing/shoes, old bicycle, unsused water jugs, and other items. Additonally the wooden raised passageway used as an emergency exit route has an old bedframe on the passageway leaning against the wall. This passageway is used as part of the emergency exit route.
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Type B
09/19/2025
Section Cited
CCR87412(a)

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87412(a) Personnel Records - The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This regulation has not been met as evidenced by:
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Licensee shall submit a plan of correction in writing showing how the facility will maintain current and up to date records at all times and complete the file for S1.
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Based on staff files reviewed, S1 does not have a complete file to review. The only items observed are the first aid card and health screening.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 01:47 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/16/2025 at 12:09 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ELLE'S CARE HOME 2
FACILITY NUMBER: 415600763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulation has not been met as evidenced by:
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Licensee shall submit a plan of correction in writing showing how the facility will maintain this regulation at all times and obtain TB testing and clearance for S1.
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Based on staff files reviewed, S1 did not receive, and does not have a record, of receiving a TB test prior to working at the facility. This poses an immediate health and safety 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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