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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603358
Report Date: 08/12/2021
Date Signed: 08/12/2021 04:29:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ELITE MANOR II RESIDENTIAL CAREFACILITY NUMBER:
374603358
ADMINISTRATOR:I CHEN LEEFACILITY TYPE:
740
ADDRESS:11065 WYNDEMERE LANETELEPHONE:
(760) 294-6889
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:William Lee, AdministratorTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry after identifying himself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out, and Administrator William Lee later arrived at the facility and met with LPA. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Mr. Lee including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility has Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.

No deficiencies were observed during today's visit. An exit interview was conducted with Mr. Lee and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was provided to him via email; he expressed that he would send LPA a confirmation email upon receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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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