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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603358
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:35:33 AM

Document Has Been Signed on 09/26/2024 11:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ELITE MANOR II RESIDENTIAL CAREFACILITY NUMBER:
374603358
ADMINISTRATOR/
DIRECTOR:		I CHEN LEEFACILITY TYPE:
740
ADDRESS:11065 WYNDEMERE LANETELEPHONE:
(760) 294-6889
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 6DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Administrator, Chen LeeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 9/26/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator, Chen Lee who was informed of the purpose of the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents. The facility also has an approved hospice waiver for one (1) and LPA was informed Resident 1 (R1) and Resident 2 (R2) are receiving hospice services at the facility. During the visit, there was three (3) staff and six (6) residents present.

LPA toured the facility with Caregiver, Norma Tosoc and reviewed records. During the tour, LPA observed indoor and outdoor pathways were free of obstructions. The facility has an in-ground swimming pool in the backyard that secured with a locked fence. Outdoor shaded seating is available for the residents in care. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and 7-day supply of non-perishable foods, all stored in a safe and healthful manner. Medications are secured in a locked kitchen cabinet. LPA and Caregiver Tosoc reviewed the physical medications for three (3) residents along with their Medication Administration Record for September 2024 and did not discover any discrepancies. Caregiver Tosoc tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen. Staff present have a criminal record clearance.

During today's visit, the facility was cited for violation of their current hospice care waiver. 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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 09/26/2024 11:35 AM - It Cannot Be Edited


Created By: Janette Romero On 09/26/2024 at 11:20 AM
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 II RESIDENTIAL CARE
FACILITY NUMBER: 374603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

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 for one (1) resident and R1 and R2 are receiving hospice services at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee stated they will submit 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: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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