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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603358
Report Date: 09/13/2022
Date Signed: 09/13/2022 11:17:17 AM


Document Has Been Signed on 09/13/2022 11:17 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 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:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Sheryl Tapia, CaregiverTIME COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Caregiver Sheryl Tapia and explained the purpose of today’s visit. The facility has a Mitigation Plan Report on file as required.

During the inspection, LPA observed appropriate COVID-19 postings at the facility front entrance and throughout the facility itself. The facility has a COVID-19 symptom and temperature screening process in place which was in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). As documented in the facility's Mitigation Plan Report (Report), the facility has a designated infection control lead person/infection preventionist who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring staff are trained in the facility's infection control procedures, and ensuring infection control measures are implemented. Also detailed in the Report, the facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents and staff with COVID-19 positive results and/or exposures. Additionally, the Report describes the facility's plan to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician, emergency personnel, and responsible party in the event the resident presents with any COVID-19 symptoms. During facility file review prior to this visit, LPA was unable to locate an Infection Control Plan (LIC9282). An Infection Control Plan was required to be submitted by June 30, 2022. The facility's Mitigation Plan Report will stay in effect until the completion and submission on the Infection Control Plan.

The following deficiency was issued during today's visit. An exit interview was conducted, and a copy of this report was provided along with Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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 09/13/2022 11:17 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ELITE MANOR II RESIDENTIAL CARE
FACILITY NUMBER: 374603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements- (c) An Infection Control Plan shall be developed by the LIcensee and shall be included in the Plan of Operation required by Section 87208.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Licensee did not comply with the section cited above in one out of one files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Licensee agrees to develop an Infection Control Plan and submit it to CCL by POC due date of 9/23/2022. LPA informed facility that form LIC9282 may be utlized to meet this requirement. LPA provided a hard copy to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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