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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603749
Report Date: 02/08/2022
Date Signed: 02/08/2022 12:30:40 PM

Document Has Been Signed on 02/08/2022 12:30 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: 120DATE:
02/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Stephanie Brown-AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a case management visit regarding an incident reported to CCL on 2/7/2022. LPA arrived and called Administrator Stephanie Brown to complete facility risk assessment. LPA informed staff that the reason for the visit was due to the incident which occurred on 2/8/2022 and was allowed entry.

During todays’ visit LPA interviewed administrator, staff and toured physical plant. On 2/8/2022 client 2 (C2) heard client 1 (C1) fall out of bed, when C2 could not awaken C1, C2 called staff who called 911. Paramedics arrived and after performing CPR declared C2 dead. Cause of death was not given.

LPA requested the following documents: Staff roster, staff schedule, needs and services plan, MAR, and Physicians Assessment for C1.

A request was made to provide a copy of the death certificate when it becomes available.

No deficiencies will be cited at this time, additional investigation is required which includes analysis of the records obtained and follow up interviews.

Exit interview held and a copy of report provided to administrator Stephanie Brown

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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