<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320096
Report Date: 07/15/2023
Date Signed: 07/18/2023 08:29:43 AM


Document Has Been Signed on 07/18/2023 08:29 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:BRICKSTONE MANORFACILITY NUMBER:
198320096
ADMINISTRATOR:DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:20551 MADISON ST.TELEPHONE:
(310) 251-2382
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
07/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:House manager Virgilio PscualTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/15/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Virgilio Pascual as the purpose of today’s visit was explained. The facility is licensed to serve 6 bedridden residents ages 60 and over, there is a hospice waiver for 6.

The facility is a single-story structure located in a residential neighborhood and consists of the following: The home consists of 6 resident bedrooms, 1 staff bedroom, 2 common bathrooms, 2 private bathrooms, a linen closet, living room, dining area, kitchen, pantry, staff work area, laundry area, toxins were observed to be locked and inaccessible to residents. There is a big outdoor shaded activity area, an attached garage that serves as storage unit for facility supplies and additional nonperishable items.

LPA conducted a records review of 2 staff record, 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 06/03/23, 1 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational, and a landline 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, alarm/censors on resident’s patio doors observed to be operational. 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..

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 07/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit the following discrepancy was cited; 87355 (e) (1-2) Criminal Record Clearance



A civil penalty of $500 was assessed, deficiency cited under California code of regulations title 22 division 6 chapter 8.


Exit interview conducted with house manager Virgilio Pascual, appeals rights explained, 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: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/18/2023 08:29 AM - 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1-2)
Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or

(2) Request a transfer of a criminal record clearance as specified in Section 8735


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interviews conducted Edilberto Bernardino is not on the facility roster and no evidence of finger print clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2023
Plan of Correction
1
2
3
4
Licensee shall ensure that staff is fingerprint cleared and assosciated to the facility by POC due date.

An immediate civil penalty is assessed
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3