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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603749
Report Date: 10/09/2023
Date Signed: 10/09/2023 04:05:33 PM

Document Has Been Signed on 10/09/2023 04:05 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: 151CENSUS: 51DATE:
10/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Stephanie Brown, AdministratorTIME COMPLETED:
04:29 PM
NARRATIVE
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On 10/09/23 Licensing Program Analyst (LPA) Mario Leon arrived at the facility to provide a complaint investigation report that the Community Care Licensing received on 05/09/23.
During the initial complaint visit, 0n 05/16/23, LPA was met by Administrator, Stephanie Brown, to tour the facility. During the tour, LPA observed tobacco scent and smoke emanating from two (2) indoor units during the tour of the facility.

The investigation consisted of the following:
On 5/16/23 LPA interviewed nine (9), out of ten (10) residents (R1-R9) and four (4) staff (S1-S4). All four (4) staff agree that smoking indoors is a violation of house rules, while three (3) clients agree the smoke is bothersome.

The investigation revealed the following:
Between the LPA and the Administrator, It has been agreed that smoking indoors is against house rules. The Administrator has agreed to provide appropriate measures to prevent clients from continuing to smoke indoors.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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Document Has Been Signed on 10/09/2023 04:05 PM - It Cannot Be Edited


Created By: Mario Leon On 10/09/2023 at 03:09 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: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2023
Section Cited
CCR
80072(a)(2)

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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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LPA and Administrator (S1) have agreed that S1 will provide guidance to, at least two residents (R1-R2), from smoking indoors any longer and will provide the (blank) last written request prior to 30-day eviction. S1 has also agreed to forward any incidents involving client safety to CCL.
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Based on LPA observation and interviews conducted (R1-R9), the facility failed to ensure clients remain to be kept in a safe environment, which poses an immediate health, safety or personal rights risk to persons in care.
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In order to prevent future occurances, S1 has agreed to provide in-service staff training regarding the staff's need to report any house rule violation.

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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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