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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881163
Report Date: 07/08/2021
Date Signed: 07/08/2021 10:33:07 AM

Document Has Been Signed on 07/08/2021 10:33 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ELITE SENIOR CAREFACILITY NUMBER:
331881163
ADMINISTRATOR:SEVILLANO, RHELLYNICKFACILITY TYPE:
740
ADDRESS:43895 BLUEWOOD CIRCLETELEPHONE:
(951) 414-9381
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 2CENSUS: 0DATE:
07/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rhellynick SevillanoTIME COMPLETED:
10:42 AM
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Licensing Program Analyst (LPA) Christine Le conducted an announced visit to the pending facility for a pre-licensing inspection. LPA met with applicant Rhellynick Sevillano.

LPA toured the facility inside and out. The pending application is for two (2) non-ambulatory residents in a Residential Care Facility for the Elderly. The following was observed, reviewed, and inspected: there is one (1) resident bedroom and one (1) resident bathroom. There are no bodies of water. The physical plant, in general, was in good repair. Buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. The outside of the facility had a shaded area with seating. The auditory devices used to monitor exits were functional. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The facility has a working telephone. There is a locked area for medications and sharps. LPA toured the bedroom. Resident bedroom had the required bedding, furniture, and functional lighting. The facility had a supply of additional linen and extra hygiene items for the residents. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a 2 day supply of perishable food items and 7 day supply of nonperishable food items. The facility menu was available for review. Dishes, glasses, and utensils were in good condition. The facility has a designated area for staff and resident files. LPA toured the resident bathroom. The bathroom was operating in a safe and sanitary condition. LPA observed grab bars. The hot water temperature measured at 112 degrees F. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. The facility was equipped with a complete first aid kit (e.g. thermometer, tweezers, scissors, antiseptic, bandages, gauze). There is adequate seating in the common areas. Night lights were maintained in the hallways. The facility had a supply of activities for the residents. Emergency lighting (e.g. flashlights) were also maintained.

The following needs to be corrected prior to licensing: 1) LPA observed unlocked cleaning supplies in the laundry room. The applicant shall ensure cleaning supplies are locked and inaccessible.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ELITE SENIOR CARE
FACILITY NUMBER: 331881163
VISIT DATE: 07/08/2021
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2) LPA did not observe non-skid mats in the bathroom. The applicant shall ensure non-skid mats are placed in the shower.
3) LPA observed a first aid kit but not a first aid manual. The applicant shall ensure the facility has a first aid manual.

Proof will be submitted to the Department by 7/11/21. An exit interview was conducted where this report was discussed and provided to the applicant.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC809 (FAS) - (06/04)
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