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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881364
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:11:47 PM


Document Has Been Signed on 11/07/2023 01:11 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
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: 6DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:ADMINISTRATOR, WILLIAM LEETIME COMPLETED:
01:15 PM
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On November 07, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit to the facility to conduct an annual licensing inspection, and met with the Administrator William Lee. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator, and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is licensed to serve six residents, five may be ambulatory and one may be non-ambulatory and is currently operating at full capacity.
Physical Plant: The facility is a single story home located at 328 Melbourne Glen, Escondido, CA, and the land- line phone number is (858)-205-1586, and is operable. The LPA observed the resident's bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected the facility bathroom, and the hot water temperature tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and three fire extinguishers, and a first aid kit with manual. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the resident. There was a designated space for the resident and staff files. Medications: The medications were, locked, and inaccessible to the residents. The overall facility is clean, and the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there were a variety of food types. Dishes and utensils are in sufficient supply and stored properly. Care & Supervision: The facility has sufficient staff, two staff at the time of this visit, and the staff were attentive and engaging the residents. Records Review: The LPA reviewed six resident files, three staff files. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Administrator, William Lee.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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