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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603749
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:57:08 PM

Document Has Been Signed on 01/03/2024 03:57 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
EL SEGUNDO ASC, 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: 151; 151CENSUS: 114DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Stephanie BrownTIME COMPLETED:
03:55 PM
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On 01/03/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Terry Santos, Assistant Administrator and later met with Stephanie Brown, Administrator and the purpose of the visit was explained. The facility is licensed to serve one hundred fifty-one (151) clients ages 18-59. Currently there are 114 clients in this facility.

The facility consists of two buildings located in a residential neighborhood. The main building includes a kitchen, dining area, lounge, and outside covered patio area.

LPA and Administrator Stephanie Brown toured both buildings. The following rooms were inspected: in building one (1) located at 1905, LPA inspected unit 22 rooms A, B, and C, unit 8 rooms A, and B, unit 9 rooms A, B, and C, and unit 10 rooms A, B, and C. Each room consisted of a bed, bedding supplies, adequate lighting, nightstand, dresser, and chair. LPA observed a storage area for the residents’ personal belongings. Building two (2) located at address 2019, LPA inspected unit 1 rooms A, and B, unit 2 rooms A, and B, unit 3 rooms A, and B, and unit 4 rooms A, and B. LPA observed that all rooms were adequately furnished within title 22 guidelines. All units have a shared bathroom. The water temperature was maintained and measured between 105.0 F and 120.0 F.

Continued on LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MANOR, THE
FACILITY NUMBER: 191603749
VISIT DATE: 01/03/2024
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LPA further observed that personal hygiene supplies were available, and storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. There was a swimming pool on the main building grounds in 1905, with a 5-foot fence surrounding the pool meeting title 22 regulations. LPA observed that the garden/plant area was well maintained, as well as the laundry area in both buildings on this visit.

The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There are several other freezers that store frozen food for the residents. Medications are centrally stored, locked, and inaccessible to clients. Fire extinguishers are fully charged. LPA observed several First Aid kits complete with manuals. Smoke and carbon monoxide detectors are operable. Exit, walkways and/or passageways were free of debris and/or hazards.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed sanitizing stations located in common areas and in the restrooms. LPA observed staff wearing face coverings and the facility had the required postings posted throughout each building.

Continued on LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MANOR, THE
FACILITY NUMBER: 191603749
VISIT DATE: 01/03/2024
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The following deficiencies were cited according to the California Code of Regulations, Title 22, Division 6:

At 10:45 A.M. LPA observed a hole in the wall next to the bathroom sink in unit 22 bathroom, LPA also observed bathroom vanity doors and bathroom tub in disrepair.

At 11:11 A.M. LPA observed mold on the wall next to tub in unit 3 bathroom.


80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

80075
Health Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.





An exit interview was conducted with Stephanie Brown, Administrator, and a copy of the Facility Evaluation Report was provided along with appeal rights.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2024 03:57 PM - It Cannot Be Edited


Created By: Elvira Gonzalez On 01/03/2024 at 02:30 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MANOR, THE
FACILITY NUMBER: 191603749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to shared bathroom in unit 22 had a hole in the wall and vanity doors in disrepair. Shared bathroom in unit 3 had mold on the wall, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee is to repair and/or patch up the hole in the wall, the vanity broken doors and the mold in bathrooms in units 22 and 3. Licensee is to submit proof of correction by POC due date to LPA Gonzalez by email or fax.
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above in not having five staff members certification within the above field which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee will provide proof first aid certification for five staff members to LPA Gonzalez via fax or email by POC due date.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


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