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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606170
Report Date: 08/30/2026
Date Signed: 08/30/2026 02:53:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/30/2026 02:53 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:GOLDEN MANOR REST HOMEFACILITY NUMBER:
197606170
ADMINISTRATOR/
DIRECTOR:		MARK INGBERFACILITY TYPE:
740
ADDRESS:3535 OVERLAND AVENUETELEPHONE:
(310) 836-0510
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY: 98; 98CENSUS: 57DATE:
08/30/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:52 AM
MET WITH:MARK INGBERTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On August 30, 2026, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced 1-year required annual visit using the inspection tool. Due to technical difficulties, LPA Richard could not generate the electronic inspection tool and instead used a printable/PDF version. LPA Richard used the inspection tools for all program types. Upon arrival at the Golden Manor Rest Home, LPA Richard verified that the facility has a mitigation plan report on file.

The facility is licensed to serve 98 residents, of whom 42 may be non-ambulatory. There are currently no hospice waivers or bedridden residents at the facility. LPA met with Judith Montoya, and we both toured the facility's interior and exterior grounds.

The facility’s designated visitation areas include the front patio, courtyard, front living room, and the resident’s bedroom. LPA observed required postings throughout the facility. The facility does not support residents with dementia and does not have a memory care unit. A room was inspected. Beds and bedding were in good condition, adequate lighting was provided, and storage for residents’ personal belongings was observed. Furniture in common areas is clean.

No weapons were found on the premises. The resident bathrooms were checked, and sufficient liquid soap and paper towels were available.

Eva M Alvarez
Antonine Richard
DATE: 08/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN MANOR REST HOME
FACILITY NUMBER: 197606170
VISIT DATE: 08/30/2026
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Toilets and water faucets were functioning properly, grab bars were secure, and the shower was free of mold or mildew. The water temperature in the resident’s room was measured at 112.3 degrees Fahrenheit, which is within the regulations for the common area. The facility maintained a comfortable temperature overall. A fire drill was conducted on June 12, 2026. All facility fees are up to date.

LPA toured the kitchen area and observed a two day supply of perishable food and a seven (7)-day supply of non-perishable food. Knives and toxins were locked and stored separately. Centrally stored medications were in their original containers and kept secure, locked, and inaccessible to residents in care. The First Aid kit was available and inaccessible to residents. Several fire extinguishers were observed throughout the facility.

Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and free of hazards; doorways were free of obstruction.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator, Judith Montoya.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Antonine Richard
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2026
LIC809 (FAS) - (06/04)
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