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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 04/06/2022
Date Signed: 04/06/2022 09:47:13 PM

Document Has Been Signed on 04/06/2022 09:47 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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:OLIVIA ISABEL MANORFACILITY NUMBER:
198601766
ADMINISTRATOR:KUNZ, ANAFACILITY TYPE:
735
ADDRESS:21515 S. FIGUEROA STREETTELEPHONE:
(310) 328-5116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 110CENSUS: 88DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Ana KunzTIME COMPLETED:
03:32 PM
NARRATIVE
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On 04/06/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ana Kunz LPA explained the purpose of today’s visit. The facility is licensed to operate for clients ages 18-59.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (55) client's room and (55) restrooms, activity room, dining area, kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate. The last fire drill was performed on 03/22/22. A working landline phone is available at the front desk.

DEFICIENCIES:
During the inspection, LPA observed Room 211 with remnants of bed bugs on the stucco ceiling and smoke detector. Staff confirmed that it was leftover from a prior pest control spray. LPA conducted inspection of rooms: 103, 106, 111, 114,121, 230, 214 and 211. The water temperature for each room was not in incompliance with Title 22 regulations and was from 126.9 - 130.9 degrees F.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766
VISIT DATE: 04/06/2022
NARRATIVE
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INFECTION CONTROL:
LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs and COVID vaccinations were conducted.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

Deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Anna Kunz.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 09:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/06/2022 at 02:44 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation and water temperature check), the licensee did not comply with the section cited above in [6] out of [8] [rooms: #106, #111, #114, #121, #230, #211] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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Licensee will adhere to Title 22 Section 80088 (e)(1) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will adjust the water heating system so that it will regulate hot water per regulations. This violation must be corrected by POC date: 04/07/22.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 09:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/06/2022 at 02:45 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview with staff), the licensee did not comply with the section cited above in room 211 (bed bugs) remnants were identified, which poses potential health, safety, or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Licensee will adhere to Title 22 Section 80087 (a)(1) and ensure no remnants of pest/bed bugs are present in the facility at all times. The licensee will have have a pest control company service room 211 for bed bugs and will repair the stucco ceiling. The violation must be corrected by POC date 04/20/22.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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