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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606565
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:43:22 PM

Document Has Been Signed on 03/28/2022 04:43 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELITE MANORFACILITY NUMBER:
197606565
ADMINISTRATOR:GLADYS PERVEZFACILITY TYPE:
740
ADDRESS:1318 PASEO VALLE VISTATELEPHONE:
(626) 967-2614
CITY:SAN DIMASSTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:GLADYS PERVEZ, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced required annual visit. LPA met with Administrator, Gladys Pervez, who assisted with the visit. The facility serves six (6), non-ambulatory elderly residents of which one (1) may be bedridden, ages 60 and above. Facility is approved for three (3) hospice residents. There are currently two (2) residents on hospice. Administrator certificate is current and the expiration date is 02/08/23.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility has a living room, office, laundry room, dining room, kitchen, five (5) resident rooms, two (2) common bathrooms, front yard and backyard. Residents' rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Adequate linen and personal hygiene supplies are observed. Common areas are observed for the ability to safely serve the needs of the residents. Smoke detectors and carbon monoxide detector are tested and operable. Fire extinguishers' last services is 03/10/22 and fully charged. Facility maintains a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable. Backyard has a shaded area for resident use. Interior and exterior space is available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Hot water temperature is measured at 118.6 degrees Fahrenheit which is within Title 22 Regulation guidelines.

(- continued in Lic 809c-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELITE MANOR
FACILITY NUMBER: 197606565
VISIT DATE: 03/28/2022
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Administrator stated there were no weapons or ammunition on premises.

Mandated documents and signages are posted in common areas. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents. Toxic substances are inaccessible to residents.

No deficiencies were observed per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator, Gladys Pervez, who’s signature on this form confirm receipt of these documents. A copy of LIC 809s report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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