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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603644
Report Date: 05/10/2024
Date Signed: 05/10/2024 04:45:35 PM

Document Has Been Signed on 05/10/2024 04:45 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 SENIOR HOMEFACILITY NUMBER:
198603644
ADMINISTRATOR/
DIRECTOR:		PERVEZ, GLADYSFACILITY TYPE:
740
ADDRESS:935 N DAMATO DRTELEPHONE:
(626) 290-1573
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 3DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:36 AM
MET WITH:Admininistrator Gladys PervezTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Reyes and Tao conducted an unannounced annual licensing inspection. LPA Reyes explained the purpose of the visit to Administrator Gladys Pervez, This facility is a Residential Care for Elderly (RCFE) to serve residents for age 60 and above. The capacity is six (6). The licensee is Elite Manor Inc. Facility has a Dementia Care program for six (6) residents. Hospice waiver was approved for five (6). Administrator Gladys Pervez has an RCFE Certificate issued for 02/09/2023 with an expiration date of 02/08/2025.

During the visit, CARE tool was used, a tour of the facility was conducted, food supply was reviewed, staff/residents were interviewed, files were reviewed, and medications were reviewed. The facility is a single family house located in a residential neighborhood; consisted of a living room, laundry room, dining room, kitchen, five (3) resident rooms, two (2) 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 operational. Fire extinguishers are fully charged. Facility maintains a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable. Sufficient supply of perishable and nonperishable foods is observed. Hot water temperature is measured at 113.5 degrees Fahrenheit which is within Title 22 Regulation guidelines. Fire drill was conducted on 04/06/24. 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.

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 809 report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 05/10/2024 04:45 PM - It Cannot Be Edited


Created By: Tyler Reyes On 05/10/2024 at 04:26 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 SENIOR HOME
FACILITY NUMBER: 198603644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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The disinfection was not was not centrally stored and locked and was accessible to residents.
Based on observations the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Administrator agreed to submit proof of staff in-service training and a written plan of correction stating how the deficiency was corrected that includes facility protocols.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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