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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603749
Report Date: 12/21/2021
Date Signed: 12/21/2021 12:52:46 PM

Document Has Been Signed on 12/21/2021 12:52 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:MANOR, THEFACILITY NUMBER:
191603749
ADMINISTRATOR:STEPHANIE BROWNFACILITY TYPE:
735
ADDRESS:1905/2019 PICO BOULEVARDTELEPHONE:
(310) 450-1748
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY: 151CENSUS: DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Terri Santos-Asst. AdministratorTIME COMPLETED:
01:00 PM
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On 06/23/21, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with assistant administrator Terri Santos and explained the purpose of today’s visit. The facility is licensed to operate for one hundred fifty-one (151) clients ages 18-59.

The facility consists of two buildings with 15 clients. The main building includes the kitchen, dining area, lounge and outside covered patio area. Rooms consist of several bedrooms and a shared bathroom. Each room has a bed, bedding supplies, adequate lighting provided, and storage for resident personal belongings

During the visit, LPA observed the facility infection control practices. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

Due to time constraints, visit will have to be continued at another time.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Terri Santos.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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