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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881364
Report Date: 11/16/2022
Date Signed: 11/16/2022 10:33:52 AM


Document Has Been Signed on 11/16/2022 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANOR MELBOURNEFACILITY NUMBER:
371881364
ADMINISTRATOR:LEE, ALANFACILITY TYPE:
740
ADDRESS:328 MELBOURNE GLENTELEPHONE:
(858) 523-8008
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 0DATE:
11/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Alan and William Lee, Applicants/AdministratorsTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:10 AM, LPA met with Applicants/Administrators Alan and William Lee. An initial application to operate a Residential Care for the Elderly (RCFE) was received to the Central Applications Bureau (CAB) on 8/4/2022 for a total capacity of six (6) residents, five (5) of which may be ambulatory and one (1) may be non-ambulatory. Fire Clearance was granted on 9/6/2022 for total capacity of six (6) residents, five (5) of which may be ambulatory and one (1) may be non-ambulatory.
LPA Danielson observed the following:
Structure:
Facility was a one story house with six (6) resident bedrooms, three (3) bathrooms, living room, family room, dining area and kitchen. There was an attached two (2) car garage as well as an attached one (1) car garage at the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each client bedroom will accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector. Per applicants, bedroom #3 has been designated and approved to accommodate a non-ambulatory resident.
Bathrooms:
All bathrooms have a working toilet, wash basin, with an adequate supply of paper towels, toilet paper, and soap. Only two (2) of the facility's bathrooms have showers. LPA observed the showers to have the required grab bars and non-skid mat. At 10:20 AM, LPA began testing bathroom water temperatures. Water temperatures were measured at 116.9, 118.5 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments
(CONTINUED ON LIC 812-C)
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MANOR MELBOURNE
FACILITY NUMBER: 371881364
VISIT DATE: 11/16/2022
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(CONTINUED FROM LIC812)
were secured in a locked drawer in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry area with washer and dryer were located in a separate room adjoining the kitchen. Cleaning supplies were secured in the locked laundry room.
Living/Family room:
There was a living room and family room with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a closet in the main hallway of the residence.
Yards/Outside:
There was a patio with adequate covered seating for all residents. Fencing secured the entire backyard. There was a swinging self-latching gate on the left side of the property. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
Both garages were free of obstructions. Emergency water supply was stored in the main garage next to the laundry room.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, Ombudsman poster, and emergency phone numbers were posted on the wall in the entryway. Emergency exit route/maps were posted in the hallway.
General items:
Three (3) fire extinguishers were charged and mounted in the laundry room, hallway, and kitchen. Smoke alarms/carbon monoxide detectors were tested and were found to be in working order. Flashlights for use in the event of an emergency were observed. Resident records will be stored in a locked cabinet in the kitchen First Aid kit with required components, and locked area for medication storage was observed in the kitchen. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Component III was completed and a hard copy was provided for future reference.

Pre-licensing is complete and this facility has no deficiencies.
Final approval of licensure is determined by the Central Applications Bureau.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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