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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881163
Report Date: 09/20/2022
Date Signed: 09/20/2022 12:57:29 PM

Document Has Been Signed on 09/20/2022 12:57 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, 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: 2DATE:
09/20/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Myla Sevillano, LicenseeTIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPA) Chinwe Nwogene conducted an unannounced case management visit to increase the capacity per licensee request. LPA met with Licensee, Myla Sevillano and Administrator, Rhellynick Sevillano and explained the purpose of the visit. Licensee requested for a capacity increase from 2 residents to 4 residents.

During the visit LPA Nwogene toured the interior/exterior of the building and visually inspected the resident bedrooms. LPA observed the Resident’s bedroom two #2 was still being used by the Licensee. LPA observed clothes, books, papers, and other personal belongings in the bedroom. Licensee stated she wasn’t expecting the visit and wasn’t ready for the inspection. Licensee stated she will notify LPA when the room is clean and ready for inspection.

Based on today’s visit, the facility is not ready for increase in capacity. Licensee will notify LPA when facility is ready for a capacity increase inspection.

An exit interview was conducted where this report was discussed, and a copy was provided to Myla Sevillano.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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