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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606565
Report Date: 03/27/2025
Date Signed: 03/27/2025 03:21:13 PM

Document Has Been Signed on 03/27/2025 03:21 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELITE MANORFACILITY NUMBER:
197606565
ADMINISTRATOR/
DIRECTOR:		GLADYS PERVEZFACILITY TYPE:
740
ADDRESS:1318 PASEO VALLE VISTATELEPHONE:
(626) 967-2614
CITY:SAN DIMASSTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
03/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Assistant Administrator - Robert SantamariaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted an unannounced required annual visit. LPA met with Caregiver, Liana Wati, who contacted administrator. Assistant Administrator Robert Santamaria joined the visit at 9:45 AM. The facility serves six (6) non-ambulatory elderly residents of which one (1) may be bedridden, ages 60 and above. Facility is approved for five (5) hospice residents.

LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

REVIEW OF FILES
· Resident Admission Agreements, Resident & Staff files, Staff fingerprint clearance, Medications, Staff First Aid Certificate, Resident Physician reports, resident medical consent.

FACILITY PHYSICAL PLANT
· Four (4) resident bedrooms and one (1) office/staff room inaccessible to residents, two (2) bathrooms (only 1 used for residents), attached car garage, shaded outdoor area, living room, kitchen and dining room, and front and back yard.

LPA reviewed three (3) staff files and four (5) resident files. Interview was conducted with one (1) staff and one (1) resident.

Report continues on page 809C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/27/2025 03:21 PM - It Cannot Be Edited


Created By: Luis DeLeon On 03/27/2025 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELITE MANOR
FACILITY NUMBER: 197606565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 two (2) out of five (5) resident medication were not given to residents in care and did not follow physician's direction which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee stated training will be provided to all staff regarding handling resident medication. A statement of medication training plan for staff will be provided to CCLD by 3/28/2025 which will indicate the subject, date, and time that training will take place. Once training is provided, a statement of training signed by all staff will be provided to CCLD.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2025 03:21 PM - It Cannot Be Edited


Created By: Luis DeLeon On 03/27/2025 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELITE MANOR
FACILITY NUMBER: 197606565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 two (2) out of five (5) resident medication which were not properly logged in the medication record log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2025
Plan of Correction
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Licensee stated training will be provided to all staff regarding documentation of resident medication. The training report shall indicate the subject, date, and time for the staff training. In addition, a statement of training signed by all staff will be provided to CCLD on 4/27/2025.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELITE MANOR
FACILITY NUMBER: 197606565
VISIT DATE: 03/27/2025
NARRATIVE
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Observations during facility tour:

· Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPAs observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents.
· Wall and floors are in good repair. Hallways were clean and free of obstructions.
· Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable.
· Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean.
· The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
· Sharps are locked in a closet and inaccessible to residents. Also, chemicals and toxics are locked and secured inaccessible to residents.
· Smoke and carbon monoxide detectors were observed and are interconnected throughout the facility. One (1) fire extinguisher was observed and was fully charged with last inspection in April 2024.
· Front and back yards are free of hazards and there were no bodies of water present at facility. Shaded area was available to residents.
· First Aid kit was inspected and in compliance.
· The medications are centrally stored and locked in a cabinet in kitchen. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all six (5) residents. LPA observed the following deficiencies in the administration of medication. Prescribed medication for resident R2 was missed for three (3) out of six (6) medications (Amolodipine 5 mg, Quetiapine 50 mg, and Trazodone HCL 50 mg). Prescribed medication for resident R4 was not properly administer when needed for blood pressure (Midodrine HCL 10 MG). In addition, prescription was being administer to resident and bubble pack had been rupture but not properly log on the records for three (3) out five (5) Residents.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D pages. Exit interview held and a copy of the report LIC9102 Technical Assitance, LIC809 and LIC809D along with appeal rights were provided to assistant administrator Robert Santamaria

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
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