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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881364
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:07:32 PM

Document Has Been Signed on 11/15/2024 02:07 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ELITE MANOR MELBOURNEFACILITY NUMBER:
371881364
ADMINISTRATOR/
DIRECTOR:		LEE, ALANFACILITY TYPE:
740
ADDRESS:328 MELBOURNE GLENTELEPHONE:
(858) 523-8008
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 5DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Administrator, William LeeTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 11/15/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Thania Gonzalez who was informed of the purpose of the visit. Administrator, William Lee arrived during the visit and was also informed of the purpose of the visit. The facility has a fire clearance for one (1) non-ambulatory and five (5) ambulatory elderly residents. As of 10/20/2022, the facility has an approved hospice waiver for one (1). During the visit, there was five (5) residents and two (2) staff present.

LPA toured the facility with Caregiver Gonzalez and reviewed records. During the tour, LPA observed indoor and outdoor pathways free of obstructions and there were no bodies of water on the premises. Outdoor shaded seating is available for the residents in care. Resident bedrooms had the required bedding, furniture, and functional lighting. Bathrooms had grab bars in the showers. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable foods and seven-day supply of non-perishable foods, all stored in a safe and healthful manner. Medications are secured in a locked kitchen cabinet. LPA also observed a hallway closet filled with additional blankets, linens, towels, incontinent and hygiene supplies. Administrator Lee tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Staff present have a criminal record clearance and are associated with the facility. The facility's certificate of liability insurance expires on 11/23/2025. A physical record review revealed Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) are receiving hospice services at the facility; therefore, the facility was cited for violation of their current hospice care waiver. Additionally, Administrator Lee showed LPA digital records of R1, R3, R4 and Resident 5's Physician's Reports noting they are all deemed non-ambulatory. This violates the facility's current fire clearance. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Lee along with an LIC 809-D, Confidential Names list (LIC 811) and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 11/15/2024 02:07 PM - It Cannot Be Edited


Created By: Janette Romero On 11/15/2024 at 01:09 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELITE MANOR MELBOURNE
FACILITY NUMBER: 371881364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted and a record review, LPA found the facility has an approved hospice waiver (dated 10/20/22) for one (1) resident and R1, R2, R3, and R4 are receiving hospice services at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Licensee stated they will email a hospice care waiver increase request to LPA by close of business on POC due date.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2024 02:07 PM - It Cannot Be Edited


Created By: Janette Romero On 11/15/2024 at 01:54 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELITE MANOR MELBOURNE
FACILITY NUMBER: 371881364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by violating their current fire clearance and retaining R1, R3, R4 and R5 who are deemed non-ambulatory, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2024
Plan of Correction
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Licensee reported R1, R3, R4 and R5 will be relocated to a licensed board and care facility with an appropriate fire clearance. Proof of correction and corroborating information will be submitted to LPA by close of business on 11/16/2024.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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