198320393-10-25-2023-11-AS-EGOZ-CWXRF4-20231025125832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320393
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:59:44 PM

Document Has Been Signed on 10/25/2023 12:59 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:	MANHATTAN PLACE		FACILITY NUMBER:	198320393
ADMINISTRATOR:	WATERS, LUTHER		FACILITY TYPE:	735
ADDRESS:	3939 SUTRO AVE		TELEPHONE:	(323) 491-6572
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90008
CAPACITY: 4		CENSUS: 3	DATE:	10/25/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Luther Waters		TIME COMPLETED:	01:15 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 10/25/2023, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an announced pre-licensing visit to this home. LPA was greeted by applicant Luther Waters and explained the purpose of today’s visit. LPA was given access to the facility. An application was submitted to CCLD on 09/03/2023 for an initial license application for an Adult Residential Facility to serve adults age range 18 through 59. The applicant requested a capacity of four (4) ambulatory clients, of which maybe one (1) may be non-ambulatory. Structure: The home is a three (3) bedroom, two (2) bathroom, one story home with detached garage situated in a residential neighborhood. The home includes a living, dining room, kitchen, and laundry area. Living room fireplace had a screen. The living area included sectional seating. The kitchen has a refrigerator and stove. Passageways, walkways, and steps inside and out are free from obstructions. Bedrooms Residents: The facility has three (3) bedrooms clients. Two rooms include a bed, chair, nightstand. One room had two beds, two chairs and two bedside tables. All bedrooms are equipped with ceiling lights and dressers, which comply with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Bathrooms: The home has two (2) bathrooms. All bathrooms have a working toilet, washbasin, and shower with non-skid mats. One bathroom also had a tub. Linens & Hygiene Supplies: Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet. Evaluation Report Continues

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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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: MANHATTAN PLACE	FACILITY NUMBER: 198320393
	VISIT DATE: 10/25/2023

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is three (3) fire extinguishers fully charged located throughout the home. Facility has a working telephone which was called by LPA and found to be operational. The applicant has an approved Infection Control Plan on file.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen drawer. Food supply is adequately stored and consist of (2) day supply of perishables and a (7) day supply of non-perishables.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. A total of five (5) interconnected smoke detector and carbon monoxide detector throughout the bedrooms and hallways.

Toxins:
All toxins are locked and stored in a locked space under kitchen sink.

Appliances:

Kitchen appliances found to be within title 22 requirements.

Evaluation Report Continues

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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: MANHATTAN PLACE	FACILITY NUMBER: 198320393
	VISIT DATE: 10/25/2023

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Water Temperature:
The water temperature was found to be withing title 22 regulations throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in hallway and contained thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in a cabinet locked in the kitchen area and inaccessible.

Resident & Staff Files:
Records of staff and residents will be stored in cabinets off in the kitchen area.
Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool on premises.

A Fire Clearance inspection was conducted on 5-15-2023 and approved for a capacity for four (4) ambulatory of which one (1) may be non-ambulatory.

Component III Orientation: Component III was completed with the Applicant during the Pre-Licensing visit. Information was provided about how to operate the facility within substantial compliance. When the applicant was asked if she understood Title 22 Regulations he responded in the affirmative.

An exit interview was conducted, and a copy of this report has been furnished to administrator. LPA Gonzalez will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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