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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203284
Report Date: 08/24/2023
Date Signed: 08/25/2023 11:02:20 AM


Document Has Been Signed on 08/25/2023 11:02 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:MICHAEL'S MANORFACILITY NUMBER:
198203284
ADMINISTRATOR:PHILIP JOHN ROMEROFACILITY TYPE:
740
ADDRESS:23704 HYNFORD PLACETELEPHONE:
(310) 539-5502
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 6DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Licensee Zenaida MacapobreTIME COMPLETED:
03:15 PM
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On 08/24/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Licensee Zenaida Macapobre as the purpose of today’s visit was explained. The facility is licensed for six (6) non-ambulatory elderly adults ages 60 and over and may retain three (3) hospice residents.

The facility is a single-story structure located in a residential neighborhood and consists of the following: The home consists of 5 Bedrooms, 4 resident bedrooms and 1 staff bedroom, 2 Bathrooms of which 1 is private, a linen closet, living room, dining area, kitchen, a stocked pantry, an outdoor shaded activity area, an attached garage that serves as storage unit and houses a washer and dryer as well as an additional freezer.

LPA conducted a records review of 2 staff records, 2 resident records and 2 Medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 08/04/23, 1 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors and auditory signals are operational. Landline and internet service was observed.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were cited.Exit interview conducted with Licensee Zenaida Macapobre, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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