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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600106
Report Date: 09/20/2022
Date Signed: 09/20/2022 03:25:51 PM

Document Has Been Signed on 09/20/2022 03:25 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:D'CORDIAL MANORFACILITY NUMBER:
198600106
ADMINISTRATOR:RENATO MADRIGALFACILITY TYPE:
735
ADDRESS:14746 ZASTROW AVETELEPHONE:
(562) 925-8125
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 2DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:David Mancilla DSPTIME COMPLETED:
03:40 PM
NARRATIVE
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On 9/20/22 at 1:31 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with DSP, David Mancilla who assisted with today’s visit.

The facility is licensed to serve 4 clients between the ages of 18 and 59 years old, ambulatory only. The facility is a two-story building in a residential area, with a kitchen, dining room, living room, 2 bedrooms for residents, 2 bedrooms for staff, 2 bathrooms, backyard with shaded area and a detached garage. Fire extinguisher observed kitchen fully charged. There are smoke detectors/ Carbon monoxide located in the facility, tested and non-operational. LPA heard smoke detector beeping during the entire visit.

LPA discussed infection control practices with DSP staff, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Report continued 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: D'CORDIAL MANOR
FACILITY NUMBER: 198600106
VISIT DATE: 09/20/2022
NARRATIVE
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All resident bedrooms are located downstairs and have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. DSP staff stated upstairs is reserved for staff only. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. LPA observed the floorboard in front of resident bathroom in disrepair. A photo was taken during the visit. The resident bathrooms are clean, and showers have nonskid materials and grab bars. The hot water temperature measured at 109.8 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE. Infection control signs were observed in the facility. Medications reviewed for all clients and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6009588735 expire 6/20/2024. Last emergency disaster drill 7/19/22.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
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Document Has Been Signed on 09/20/2022 03:25 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 09/20/2022 at 02:58 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: D'CORDIAL MANOR
FACILITY NUMBER: 198600106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Buildings and Grounds

The facility shall be clean, sanitary and in good repair at all times for the safety and well being of the clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which smoke detectors was beeping through out the visit. LPA tested the smoke detector and it was non operational, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee shall repair smoke alarm 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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/20/2022 03:25 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 09/20/2022 at 03:09 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: D'CORDIAL MANOR
FACILITY NUMBER: 198600106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds

The facility shall be clean, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, because during the visit LPA observed broken floor board in front of resident bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2022
Plan of Correction
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Licensee will ensure the facility is in good repair and replaced the broken floor board. A photo will be sent to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022


LIC809 (FAS) - (06/04)
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