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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603749
Report Date: 04/01/2022
Date Signed: 04/01/2022 12:57:41 PM

Document Has Been Signed on 04/01/2022 12:57 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
MONTEREY 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: 112DATE:
04/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Stephanie Brown, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced case management visit to the above facility. LPA was met by Terry Santos, Assistant Administrator and later met with Stephanie Brown, Administrator and the purpose of the visit was explained.

LPA Soto conducted visit due to an SIR submitted and dated 03/29/22, C#1 was stabbed by unknown assailant/s. LPA interviewed administrator and House Keeper. Apparently, C#1 was assaulted at the beach trying to separate a fight between two other unknown individuals. 911 was called and C#1 was transported to hospital. C#1 returned to facility next day with new doctor's orders. Police was also contacted on the same time. They conducted their investigation and incident occurred outside the facility. Toured the West stairwell, room #24A, Administrative offices, and courtyard. C#1 was unavailable to interview, C#1 was not in the facility at the time of visit. LPA obtained the following documents: Resident roster, Staff roster, SMPD report #, Detectives card, and Discharge documents from hospital for C#1.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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