198603644-5-23-2023-28-AS-BTAO-CS4RA8-20230523125042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603644
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:51:56 PM

Document Has Been Signed on 05/23/2023 12:51 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 SENIOR HOME		FACILITY NUMBER:	198603644
ADMINISTRATOR:	PERVEZ, GLADYS		FACILITY TYPE:	740
ADDRESS:	935 N DAMATO DR		TELEPHONE:	(626) 290-1573
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY: 6		CENSUS: 0	DATE:	05/23/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Gladys Pervez, applicant		TIME COMPLETED:	01:00 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) Tao conducted an announced pre-licensing inspection. This is an initial application applying for Residential Care for Elderly to serve residents for age 60 and above. LPA met with Gladys Pervez, applicant/ administrator. The requested capacity is six (6). No resident at the time of visit. The licensee is Elite Manor Inc. Facility has a Dementia Care program for six (6) residents. Hospice waiver was approved for five (5). Fire clearance: Fire clearance was granted on 01/25/23 for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place. Auditory device is installed at all exits and operational. Structure: The property is a single-family residence located in a neighborhood, consisting of three (3) bedrooms, two (2) bathrooms, kitchen, dining area, laundry room, detached garage, and living room with a TV. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Signal system and Garage: Facility does not have a signal system. Garage is not accessible to residents. Bedrooms for Residents: Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. (- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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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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 SENIOR HOME	FACILITY NUMBER: 198603644
	VISIT DATE: 05/23/2023

NARRATIVE

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Bathrooms:
Toilet, wash basin, bathtub/shower in bathrooms are operational. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash cloths and towels are observed.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supplies consist of two days of perishable and two weeks of non-perishable were observed.

Medications, First-Aid Kit & Book:
Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze.

Smoke Detectors:
Smoke /carbon monoxide detectors are tested and operational. They are located in hallways and each bedroom.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. A refrigerator was located in the kitchen. Refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat. (-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 SENIOR HOME	FACILITY NUMBER: 198603644
	VISIT DATE: 05/23/2023

NARRATIVE

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Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Residents & Staff Files:
Locked cabinets for records of staff and residents are installed and available. No residents file are observed since no resident was in place. Applicant will not handle cash resources for residents.

Water Temperature:
Tested at 118.0 degrees Fahrenheit.

Menu and phone:
Menus are available for review. Free landline telephone is available for residents’ use and operable.

Fire extinguishers:
Fire extinguisher is located in the kitchen mounted on the wall. They are fully charged, and last service was done in 1/25/23.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials for the residents’ use and commensurate with the plan of operation. (- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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 SENIOR HOME	FACILITY NUMBER: 198603644
	VISIT DATE: 05/23/2023

NARRATIVE

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Pool:
No bodies of water located at the facility.

Finding:
No issue was observed during today’s visit.
Applicant Gladys stated the current fire clearance did not have bedridden approved; however, applicant may request to have a fire inspection visit for approving bedridden in the near future.

Exit:
Component III was conducted during this visit.

A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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