374603358-9-27-2023-18-AS-JSRS-CW3SZ8-20230927141842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603358
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:18:56 PM

Document Has Been Signed on 09/27/2023 02:18 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 II RESIDENTIAL CARE		FACILITY NUMBER:	374603358
ADMINISTRATOR:	I CHEN LEE		FACILITY TYPE:	740
ADDRESS:	11065 WYNDEMERE LANE		TELEPHONE:	(760) 294-6889
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 5	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	William Lee, Administrator		TIME COMPLETED:	02:25 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	Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived to the facility to conduct a required annual inspection and was greeted by Caregiver, Norma Tosoc. Licensee I Chen Lee and Administrator William Lee arrived shortly. Present at the facility were two (2) staff and five (5) clients. The facility is approved for six (6) non-ambulatory elderly residents; age 60 and above. Hospice care waiver is approved for one (1). LPA conducted staff and client interviews. The facility is a six (6) bedroom, three (3) bathroom house. Each client has a private room. LPA toured the facility and conducted a general overall inspection of the facility inside and outside. Passageways were observed to be free of obstructions. LPA observed each bedroom to be clean and odor free with the required furnishings. Furniture throughout the facility was in good repair. The facility temperate was 75 degrees. Hot water temperature tested at 122.5 degrees Fahrenheit which is above the maximum hot water temperature of 120 degrees; however LPA observed hot water warning signs posted throughout all bathrooms. Each bathroom contained grab bars for each toilet, bathtub and shower; and non-skid mats or strips in shower or bathtub. LPA observed the kitchen in its entirety. The kitchen appeared clean and odor free. Dishes, cups, pots and pans were observed to be of good quality and quantity. The facility contains a sufficient supply of perishable and non-perishable foods. The facility has an in-ground pool in the back yard secured with fencing that is in compliant with the Health and Safety code. LPA observed the gate was locked with an automatic latch mechanism. There are no firearms/weapons stored in the facility. Continue on LIC809C....

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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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Document Has Been Signed on 09/27/2023 02:18 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 II RESIDENTIAL CARE	FACILITY NUMBER: 374603358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in [5] out of [total 5]. LPA observed medication not properly logged onto medication record log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	See page two 809D for deficiency cited. Administrator will review medication record keeping regulations. Administrator informed LPA that a refresher training on medication record keeping will be conducted with all staff. Proof of training will be provided to the Department by POC due 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 and interview, the licensee did not comply with the section cited above in [5] out of [5] total count.LPA observed medication stored in medication cups and not in its original containers. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator will review medication regulations and provide refresher training on medication management and dispensement to all staff. Administrator will submit proof of training conducted to the Department by the POC due 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: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 II RESIDENTIAL CARE	FACILITY NUMBER: 374603358
	VISIT DATE: 09/27/2023

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Continued from LIC809....

LPA reviewed facility records to ensure staff have received required training and criminal record clearances. LPA also determined there were no excluded personnel employed by the facility. All staff are properly associated to the facility with current first aid certification. First aid kit was available and contained the necessary items. LPA also reviewed client files to determine if residents have medical assessments on file. All client files contain required documents and are current. William Lee is the certified administrator for the facility and certificate is valid through 2/14/2025. LPA observed required postings throughout the facility. Drills are conducted quarterly and the last drill was 9/1/2023. Fire extinguishers and smoke alarms were observed to be operable.

LPA reviewed medications and the following deficiencies were observed:
- medications were stored in a locked cabinet in the kitchen, however medications were pre-prepared in medication cups. LPA informed Administrator medication is to be always stored and dispensed from its original container.
-LPA reviewed medication log and observed that morning medications were given but not initialed/recorded by staff in the medication log. LPA was informed staff usually log medications given later in the day. LPA informed Administrator medications dispensed are required to be logged and signed off by staff at the time it is given.

An exit interview was conducted. A copy of this report along with a LIC809D and copy of Appeal Rights was provided to Administrator, William Lee.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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