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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607305
Report Date: 11/02/2023
Date Signed: 11/08/2023 12:12:41 PM


Document Has Been Signed on 11/08/2023 12:12 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:CARRILLO MANORFACILITY NUMBER:
197607305
ADMINISTRATOR:ROWENA MARANTAL-CARRILLOFACILITY TYPE:
740
ADDRESS:14006 SYLVANWOOD AVE.TELEPHONE:
2132811439
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 3DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Rowena Marantal Carrillo TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced required 1 year visit and met with Administrator, Rowena Marantal Carrillo to discuss the purpose for todays visit.

The facility is a single-story building in a residential area, with a kitchen, dining room, living room, den, 4 bedrooms, 2 bathrooms, backyard with shaded area. Fire extinguisher observed kitchen fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.
Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and 2 days of non perishables and 7 days of perishables. Hot water temperature measured at degrees F. Infection control signs were observed throughout the facility. LPA observed a sufficient supply of PPE. Medications reviewed for all clients and appears to be given as prescribed. Last emergency disaster drill was conducted on 09/21/2023.
Administrator Certificate for Rowena Marantal Carrillo # 6014763735 expired 3/26/2023,showed paper work and cancelled check. The administrator certificate is still pending.

The backyard was observed to have storage materials and debris, the front yard contained an inoperable car.
Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Administrator / Appeal Rights Provided / A Copy of the Report given to Administrator Rowena Marantal Castillo.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/08/2023 12:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CARRILLO MANOR
FACILITY NUMBER: 197607305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(2)

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 as the water temperature measured between 96.2-97.4 degreed f, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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The licensee/adminstrator will log the temperature daily and on the 7th day, email/fax the log to the LPA to clear the POC.
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 as the facility contained an inoperable car, wood and debris in the back yard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2023
Plan of Correction
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The licensee/Adminstrator will have the items removed by POC date 12/02/23.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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