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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881163
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:12:54 PM

Document Has Been Signed on 07/11/2024 03:12 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/
DIRECTOR:		SEVILLANO, RHELLYNICKFACILITY TYPE:
740
ADDRESS:43895 BLUEWOOD CIRCLETELEPHONE:
(951) 414-9381
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:RHELLYNICK SEVILLANOTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On July 11, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Rhellynick, the Administrator. The facility file review was conducted in the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for four Adults but has since requested approval for a capacity increase of six Elderly Adults (740).

LPA Mixson toured the facility along with Administrator, Rhellynick, and made observations pertaining to the one year required annual. The facility was inspected inside and outside, there were no obstructions or debris to the indoor or outdoor passageways currently. The facility is a two-story home located at 43895 Bluewood Circle Temecula, CA 92592.

Physical Plant: The facility phone number is (951) 414-9381 and is currently operable. LPA Mixson observed all three residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected the two facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The medications were not observed to be pre-filled during this inspection, and the Fire and/or Disaster Drills were logged and conducted quarterly.

CONTINUED ON NEXT PAGE 809-C

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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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: 07/11/2024
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The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit, and there were safety lights for night throughout the facility, along with a first aid kit and manual.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Food shopping for groceries once a week or as needed.

Care & Supervision: Facility has sufficient staff, three staff on site at the time of this visit for the current residents in care. Rhellynick Sevillano, Administrator’s license is posted in the facility with an expiration date of 11/04/2024.


Records Review: The LPA reviewed resident and staff files, conducted three staff interviews and several resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and proved to the Administrator, Rhellynick Sevillano.



SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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