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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603749
Report Date: 09/23/2024
Date Signed: 09/23/2024 04:12:06 PM

Document Has Been Signed on 09/23/2024 04:12 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MANOR, THEFACILITY NUMBER:
191603749
ADMINISTRATOR/
DIRECTOR:		STEPHANIE BROWNFACILITY TYPE:
735
ADDRESS:1905/2019 PICO BOULEVARDTELEPHONE:
(310) 450-1748
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY: 151CENSUS: 111DATE:
09/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Stephanie Brown - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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tOn 09/23/24 Licensing Program Analyst, LPA Troy Watson conducted a Case Management visit to follow up on the death reported for client #1 (C1). LPA was greeted by the Administrator Stephanie Brown and explained the purpose of the visit was to gather information about the death of (C1).

The regional office received a copy of the death report from the facility and reported the death of (C1) on 09/17/24. The death report stated that on 09/17/24 (C1) was pronounced dead at 12:40 P.M. at UCLA Santa Monica.C1 was sent to the hospital on an emergency medical services (EMS) and was admitted to the hospital on 09/17/24 due to a fall from the second floor of the residence. Interviews were conducted with the staff #13 (S1- S13) and #2 clients (C1- C2) were interviewed on this visit.

The following documents were collected:
· ID and Emergency Information
· Admission Agreement
· Physician Report for Community Care Facilities LIC 602A
· Preplacement Appraisal Information LIC 603
· Appraisal/Needs and Service Plan
· Medications (MAR)
· Hospital discharge records

No citations issued during this visit.
An exit interview was conducted with Stephanie Brown and a hard copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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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