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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600104
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:10:44 PM

Document Has Been Signed on 09/07/2023 04:10 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:MIRADA MANORFACILITY NUMBER:
198600104
ADMINISTRATOR:ROBERT TALENSFACILITY TYPE:
735
ADDRESS:14926 COSTA MESA DRTELEPHONE:
(714) 994-4749
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 3DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Assistant Administrator Eloisa TalensTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Assistant Administrator Eloisa Talens and the purpose of the visit was discussed.

Structure/Physical Plant: The facility is part of a single story home located in a residential area and contains the following: living room, dining room, office, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (3) client rooms, (2) bathrooms for clients and one (1) live in staff room; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to clients for storage, with washer and dryer. The residence is equipped with air conditioning. Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Client Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There are (2) cordless phone for residents use. Fire Extinguisher 1 and 2 fully charged and up to date Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Knives, cutlery and other sharps inaccessible to residents. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working, all detectors tested and operational. (2) Fire extinguishers observed. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to residents. First aid kit observed. Postings: Required wall postings observed. Residents & Staff Files: LPA reviewed (3) of (3) Client medication records and files , as well as three (3) Staff Files . Emergency Disaster Plan observed. Plan of Operations Observed. Infection Control Plan Observed.


Inspection tool was completed and deficiency is being cited on 809-D page. Exit interview was conducted, and a copy of this report and appeal rights was provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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Document Has Been Signed on 09/07/2023 04:10 PM - It Cannot Be Edited


Created By: Jose Villalobos On 09/07/2023 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MIRADA MANOR
FACILITY NUMBER: 198600104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in as the last fire drill was conducted on 1/3/23 and the last earthquake drill on 10/4/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Facility to conduct a drill and provide documentation of drill conducted to Licensing along with signatures or partipicants by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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