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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881163
Report Date: 10/28/2022
Date Signed: 10/28/2022 11:30:36 AM

Document Has Been Signed on 10/28/2022 11:30 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: 2DATE:
10/28/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Myla Sevillano, Licensee
Rhellynick Sevillano, Administrator		TIME COMPLETED:
10:20 AM
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Licensing Program Analysts (LPAs) Chinwe Nwogene conducted an announced 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. At the time of visit there was two #2 residents, and two #2 staff present.

Licensee requested for a capacity increase from 2 residents to 4 residents. A Fire Clearance was approved on 9/2/2022 for two #2 additional non-ambulatory residents. Facility sketch on file shows sufficient square footage in the facility and activity rooms to accommodate the requested capacity. LPA Nwogene discussed the facility sketch with Licensee. Resident bedroom two #2 has been approved for two non-ambulatory clients. LPA Nwogene confirmed that Resident bedrooms one #1 and two #2 has an exit to the outside of the facility, as well as a walk-in shower. LPA Nwogene toured the interior/exterior of the building and visually inspected the resident bedrooms. LPA Nwogene confirmed that all identified shared rooms are large enough to accommodate the required furniture for two residents without inhibiting movement into and throughout the rooms. LPA Nwogene additionally confirmed that there are sufficient bathrooms in the facility to meet Title 22 requirements for ratio of residents to bathrooms.

The physical plant is ready for increase in capacity. LPA will submit file for capacity increase approval. The final approval of capacity increase is contingent upon LPM's final file review. Licensee will be notified by LPA once capacity increase has been approved by licensing. If capacity increase is approved, new license will follow in the mail after phone notification by LPA with Licensee.

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

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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