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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881163
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:00:46 PM


Document Has Been Signed on 04/18/2024 02:00 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:ELITE SENIOR CAREFACILITY NUMBER:
331881163
ADMINISTRATOR:SEVILLANO, RHELLYNICKFACILITY TYPE:
740
ADDRESS:43895 BLUEWOOD CIRCLETELEPHONE:
(951) 414-9381
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:4CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Myla and Rhellynick SevillanoTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an announced case management visit to increase the capacity per licensee request. LPA met with Administrator Rhellynick Sevillano and Licensee Myla Sevillano and explained the purpose of the visit. At the time of visit there were 4 residents.

Licensee requested a capacity increase from four (4) non-ambulatory residents to six (6) non-ambulatory residents. A Fire Clearance was approved on 03/26/24 for two (2) additional non-ambulatory resident. Facility sketch on file shows sufficient square footage in the facility and activity rooms to accommodate the requested capacity. LPA discussed the facility sketch with Licensee which provided amble space for 43 residents. LPA toured the interior/exterior of the building and visually inspected the resident bedrooms. LPA confirmed that all identified shared rooms are large enough to accommodate the required furniture for two residents without inhibiting movement into and throughout the rooms. The facility has three (3) bedrooms for the residents and 3 bathrooms. The facility has 1 additional bedroom for staff.

The physical plant is ready for increase in capacity. LPA will submit file for capacity increase approval. The final approval of capacity increase is contingent upon LPM's final file review. Licensee will be notified by LPA once capacity increase has been approved by licensing. If capacity increase is approved, new license will follow in the mail after phone notification by LPA with Licensee.

An exit interview was conducted where this report was discussed with and a copy was provided to Sevillano.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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