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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603784
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:25:36 PM

Document Has Been Signed on 04/18/2024 12:25 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAITH MANORFACILITY NUMBER:
197603784
ADMINISTRATOR/
DIRECTOR:		CLAREL MARTINEFACILITY TYPE:
735
ADDRESS:1832 SOUTH ARLINGTON AVE.TELEPHONE:
(323) 737-2310
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 21CENSUS: 17DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:House Manager Tompi Sihamau TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 4/18/2024 at 9:20 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit in conjunction with a case management visit. The purpose of the visit was explained to Administrator Clarel Martine and House Manager Tompi Sihamau.

During the investigation LPA observed and took photos of that the bathroom in bedroom #5 did not have a door. Staff stated there is usually a curtain used in replace of the door. LPA also observed dirt in the tub of bathroom #5, cigarette burns on the mattress of room #12, broken dresser in room #8, and a hole in the ceiling of bathroom#2. Staff stated the handy man is working on it.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit


Interview Conducted with House Manager/ Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 12:25 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 04/18/2024 at 11:38 AM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/18/2024
Section Cited
CCR
80087(a)

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Buildings and Grounds
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 was not met as evidence by:
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Adminstrator will ensure that repairs are made, hole are patched up, and mattress is replaced by POC due date. Administrator will send LPA photos that repairs have been made.
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This was not met, as evidenced by observation of hole in ceiling of bathroom #2, dirt in the tub of bathroom of bedroom #5, mattress has cigarette burns in bedroom #12, and dresser in disrepair in bedroom #8-, which poses a potential health,
safety, or personal rights risk to persons in care.
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Type B
05/18/2024
Section Cited
CCR85088(b)(4)

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85088
Fixtures, Furniture, Equipment and Supplies
(b) Toilet, washbasin, bath and shower fixtures shall at a minimum meet the following requirements: (4) Individual privacy shall be provided in all toilet, bath and shower areas.
This requirement was not met as evidence by:
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The administrator will ensure adequate privcy in the bathroom by POC due date. Photo proof will be sent to the LPA.
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LPA observed the bathroom in bedroom #5 without a door. which poses a potential health, safety, or personal rights risk to persons in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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