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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602797
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:13:08 PM


Document Has Been Signed on 06/02/2023 04:13 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ELITE MANOR RESIDENTIAL CAREFACILITY NUMBER:
374602797
ADMINISTRATOR:I. CHEN LEEFACILITY TYPE:
740
ADDRESS:1433 FERRARA COURTTELEPHONE:
(858) 729-3786
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:6CENSUS: 5DATE:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator William LeeTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/2/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to complete an investigation. LPA was greeted by Caregiver Lorenza Tuazon Faeldan who was informed of the purpose of the visit. Administrator William Lee arrived during the visit.

During this visit, LPA discovered the following deficiencies:

Caregivers John Paul Mabunga Hernandez and Lorenza Tuazon Faeldan are not associated to the facility.

During record review, LPA observed the facility had Medication Administration Records for R1, R2, R3, R4, and R5, that were not completed for today's morning medications.

Also observed, unidentified medication in R1's medication container.

R1's file was missing the following documentation:
Admission agreement, medical assessment, consent forms, weight record, identification, immunization record, TB test, safeguards for cash resources, safeguards for property/valuables, personal rights, cash resources information.

R4's file was missing the following documentation:
Admission agreement, medical assessment, consent forms, weight record, identification, emergency information, immunization record, TB test, safeguards for cash resources, safeguards for property/valuables, personal rights, cash resources information.


This report was discussed with Administrator Lee and a copy was provided along with an LIC809, LIC809-D, LIC421BG and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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


Document Has Been Signed on 06/02/2023 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ELITE MANOR RESIDENTIAL CARE
FACILITY NUMBER: 374602797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2023
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will obtain files for each resident and ensure a file is completed and obtained for any future residents prior to admission. Licensee to provide proof of correction to CCLD by close of business on 6/5/2023.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above by failing to maintain a current record for 2 out of 5 residents at the facility.
8
9
10
11
12
13
14
Type A
06/05/2023
Section Cited
CCR87355(e)(2)

1
2
3
4
5
6
7
(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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to associate the 2 staff and provide proof of correction to CCLD by close of business on 6/5/2023.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by failing to associate 2 out of 5 staff employed at the facility.
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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ELITE MANOR RESIDENTIAL CARE
FACILITY NUMBER: 374602797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
87465(e)

1
2
3
4
5
6
7
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to obtain new medication with proper label and provide staff training on proper dispensing and disposing of medication. Licensee to provide proof of correction to CCLD by close of business on 6/9/2023.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above by having a bottle of unidentified medication in R1's medication container.
8
9
10
11
12
13
14
Type B
06/09/2023
Section Cited
CCR87465(a)(4)

1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 1 of 1