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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881163
Report Date: 10/28/2022
Date Signed: 11/14/2022 10:35:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2022 and conducted by Evaluator Chinwe Nwogene
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220912111656
FACILITY NAME:ELITE SENIOR CAREFACILITY NUMBER:
331881163
ADMINISTRATOR:SEVILLANO, RHELLYNICKFACILITY TYPE:
740
ADDRESS:43895 BLUEWOOD CIRCLETELEPHONE:
(951) 414-9381
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:2CENSUS: 2DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Myla Sevillano, Licensee
Rhellynick Sevillano, Administrator		TIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sleeping in unpermitted room
Resident's bedroom door had lock on outside
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 28, 2022, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an unannounced visit to conclude the complaint investigation into the allegation listed above. LPA met with Licensee, Myla Sevillano and Administrator, Rhellynick Sevillano and discussed the purpose of the visit. During the investigation LPA interviewed resident and staff and conducted an inspection of the facility.
Regarding the allegation “Staff sleeping in unpermitted room”. It was alleged staff were sleeping in an unpermitted room. LPA interviewed Administrator who acknowledged the dining room was being used as a staff room and had two #2 beds but was removed during the Fire clearance inspection. LPA inspected the dining room and verified the beds has been removed.
Regarding the allegation “Resident's bedroom door had lock on outside”. LPA interviewed administrator who stated the lock was put in place because resident one #1 (R1) has a mild cognitive disorder and the lock prevents R1 from wandering at night when staff is sleeping. Administrator also stated the lock was removed during the Fire clearance inspection. LPA inspected staff room and the fire door, LPA observed there was still a lock on the fire door. Administrator immediately removed the lock.
Based on LPA observations and interviews, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) are being cited on the attached LIC9099D. An exit interview was conducted with, and a copy of this report was reviewed and provided along with appeal rights to Myla Sevillano.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20220912111656
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ELITE SENIOR CARE
FACILITY NUMBER: 331881163
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2022
Section Cited
CCR
87202(a)(1)
1
2
3
4
5
6
7
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(1) Non-ambulatory persons.
1
2
3
4
5
6
7
Although Licensee removed the locks, Licensee, Myla stated a written statment of understanding of the regulation cited will be provided to LPA by the POC due date 10/29/2022.
8
9
10
11
12
13
14
Based on LPA's observation and interview the licensee did not comply with the section cited above by installin a lock on the fire door of resident bedroom one #1 which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
11/07/2022
Section Cited
CCR
87208(a)(7)(a)
1
2
3
4
5
6
7
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation.
(7) Sketches, showing dimensions;
(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended…
1
2
3
4
5
6
7
Although Licensee removed the two #2 beds, Licensee, Myla stated a written statment of understanding of the regulation cited will be provided to LPA by the POC due date 11/7/2022.
8
9
10
11
12
13
14
Based on LPA's observation and interview the licensee did not comply with the section cited above by using the dining room as a staff bedroom which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2