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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600484
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:19:56 PM

Document Has Been Signed on 03/18/2024 03:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MANAGUA CAREFACILITY NUMBER:
198600484
ADMINISTRATOR:HELLER, ESTERA L.FACILITY TYPE:
735
ADDRESS:2515 MOUNTAIN BROOK DRIVETELEPHONE:
(626) 333-0402
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 5CENSUS: 5DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Estera Heller TIME COMPLETED:
03:30 PM
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Licensing Program Analyst(s) (LPA) Jose Villalobos and Tyler Reyes conducted an unannounced Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Estera Heller and the purpose of the visit was discussed. The following (CARE) tool domains were utilized during todays inspection:

Infection Control:
  • COVID-19 screening is no longer in place. The facility has an approved mitigation plan and was requested to provide LPA the Infection Control Plan for review.


Operational Requirements:
  • Facility operating within the fire clearance of (5) for all clients to be ambulatory .

Physical Plant/Environment Safety:
  • The facility is located in a residential area and includes: Living room, family room, kitchen, dining area, 4 bedrooms, 2 bathrooms, laundry area and an attached garage.
  • The physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to clients
  • Fire Alarms were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Client Rights-Information
  • No postural Supports Observed
  • Internet source provided to clients in care. Required postings observed.

Health Related Services:
  • Five (5) Client centrally stored medications were reviewed.
Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MANAGUA CARE
FACILITY NUMBER: 198600484
VISIT DATE: 03/18/2024
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Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.

Staffing:
  • Sufficient staff observed to meet clients needs
  • Facility currently provides care and supervision for a total of five (5) Clients.

Personnel Records-Training:
  • Administrator on record is current
  • Staff have criminal background clearance and training.
  • Six (6) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR and CPI training was observed. Staff file have criminal record clearances and are associated.

Client Records-Incident Reports:
  • A total of Five (5) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.

Incident Medical and Dental:
  • (0) Clients have prohibited or restricted health condition.
  • (0) Clients with Staph or other Serious, Communicable infections

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610 is in place. Facility to complete new LIC 610D

Emergency intervention:
  • No use of manual restraint or seclusion was observed. Emergency Intervention staff training not needed

All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, No deficiencies are being cited, but facility was provided a technical violation(s). Exit Interview Conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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