374602797-4-29-2024-18-AS-JSRS-D4SUXB-20240429155804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602797
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:58:13 PM

Document Has Been Signed on 04/29/2024 03:58 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 MANOR RESIDENTIAL CARE		FACILITY NUMBER:	374602797
ADMINISTRATOR:	I. CHEN LEE		FACILITY TYPE:	740
ADDRESS:	1433 FERRARA COURT		TELEPHONE:	(858) 729-3786
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	William Lee, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that five (5) clients live at this facility. There are currently two (2) staff members present. The Administrator, William Lee conducted the tour. There is an Infection Control Plan on file. The facility is a one story, six bedroom, three bathroom home.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA reviewed client records. Client records contained current physician reports and all required documents.

Personnel Records/Training/and Staffing- LPA reviewed employee records. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. All records were on file and up to date.

Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 118 degrees F. Laundry is done in the locked laundry room.

(Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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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Document Has Been Signed on 04/29/2024 03:58 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 ASC, 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: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA observed cleaning stored in an unlocked cabinet under the kitchen sink. The licensee did not comply with the section cited above in [5] out of [5] objects which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Administrator will remove the items so that they are inaccessible to residents and will install a lock on the cabinet door. Administrator will provide additional training on the above regulation and will submit proof of training by POC date.

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, medications were observed to be stored in pill cups. The licensee did not comply with the section cited above in [5] out of [5] persons) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Medications were immediately destroyed and Administrator will schedule additional training on medication storage and dispensing. Administrator will provide proof of training by POC date.

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELITE MANOR RESIDENTIAL CARE	FACILITY NUMBER: 374602797
	VISIT DATE: 04/29/2024

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There is a locked cabinet for storing laundry soap and other chemicals, however LPA observed kitchen cleaning agents stored under the kitchen sink in an unlocked cabinet. Citation issued.

All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is a secured fireplace at this facility. There is not a pool at the facility. The facility performed the fire and emergency drills 2/15/2024. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were observed to be operable.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA observed the following deficiency:
--Medication was prepared and stored in pill containers for the evening distribution. Citation issued.

An exit interview was conducted and a copy of this report was provided along with LIC 811, LIC 809D, and Appeal Rights to the Administrator..

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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