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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320096
Report Date: 06/28/2024
Date Signed: 06/28/2024 02:19:18 PM


Document Has Been Signed on 06/28/2024 02:19 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, 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: 6DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Milagros 'Mila' SantoTIME COMPLETED:
02:30 PM
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On 06/28/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Caregiver, Milagros ‘Mila’ Santos, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) bedridden residents over the age of 60 and has been approved for a hospice waiver for six (6). The facility currently has six (6) residents.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood and consists of the following: 6 resident bedrooms, 1 staff bedroom, 2 common bathrooms, 2 private bathrooms, living room, dining area, kitchen, staff work area, laundry area, and attached garage. There is an outdoor activity area with a table with umbrella and chairs. There is an additional table and chairs in the front of the home. LPA observed all walkways around the home to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all rooms and found them to be clean and in good repair. LPA observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an additional supply of linens stored in a
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 06/28/2024
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cabinet in the office area. All linens and mattress were observed in good condition. All rooms were observed to have ample lighting.

Bathrooms LPA observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPA observed an ample supply of towels and hygiene products available for residents. The water temperature measured between 110.2-degrees and 114.0-degrees Fahrenheit.

Kitchen LPA observed the kitchen to be clean and sanitary. LPA observed all appliances to be operable. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly labeled, packaged, and stored. LPA observed knives and sharps to be secured in a locked drawer and are inaccessible to residents. LPA observed a sample menu posted in the dining room. LPA observed cleaning supplies to be secured in cabinet in the laundry area and are inaccessible to residents. The water measured 113.4-degrees Fahrenheit.


Common Rooms LPA observed the living room to have four (4) recliners and a large couch to accommodate all residents. LPA observed in the dining room a large table to accommodate all residents. LPA observed activities and reading material available for residents. LPA did observe a screened fireplace that is inaccessible to
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 06/28/2024
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residents. All walkways and hallways in the home were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature. All rooms and hallways were observed to have ample lighting.

File Review/Interviews LPA reviewed six (6) resident files and found they contained the required documents. LPA interviewed three (3) residents who are happy with the service and care they receive at the facility. LPA reviewed the Administrator file, and two (2) staff files and found they contained the required documents, certification, and training. LPA interviewed two (2) staff who were able to answer questions regarding resident care, policies, procedures, and resident personal rights. LPA observed the administrator’s Administrator Certificate is valid till 09/17/25. LPA observed all licensing fees are current.

Safety LPA observed the smoke detectors and carbon monoxide detector to be operable. LPA observed a fully charged fire extinguisher last serviced on 10/20/23, located at the entrance of the kitchen. The last inspection conducted by the Torrance Fire Department was on 06/17/24. The last emergency drill was conducted on 06/04/24. All doors exiting the facility has a sensor/alarm that informs staff when a door is opened. The facility has a working landline telephone. LPA observed the facility’s Emergency and Disaster Plan posted in the office area in the dining room. LPA observed all required posting, posted throughout the facility.

Medications LPA observed medications secured in a locked closet in the office space in the dining room and are inaccessible to residents. LPA observed medications to be in their original packaging. LPA reviewed the medications and

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 06/28/2024
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Medication Administration Record (MAR) for six (6) residents. LPA observed Six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records.

Infection Control During today’s visit, LPA observed the facility’s infection control practice. Before you enter the facility there is a table with a visitor log and hand sanitizer. Upon entering the facility, LPA observed a cart with masks and Personal Protective Equipment (PPE). LPA observed all required Infection Control signs posted throughout the facility. LPA observed a 30-day supply of PPE.

During today’s visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Caregiver, Milagros ‘Mila’ Santos, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4