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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:47:58 PM

Document Has Been Signed on 04/19/2022 02:47 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:
04/19/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Dario Esguerra TIME COMPLETED:
01:59 PM
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On 04/19/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Proof of Correction visit at this facility and met with House Manager Dairo Esguerra and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check.

The facility was cited with a Type B Section 80087(a)(1) Building and Grounds on 04/06/22. Client room 211 room 211 was identified with (bed bugs) remnants were on the ceiling and smoke detector equipment.

LPA conducted an in-person visit by inspecting the interior and exterior of the facility. LPA observed that the Licensee corrected the violation cited on 04/06/22. The facility is now in compliance with the California Code of Regulations Title 22 Division 6.

An exit interview was conducted and a Facility Evaluation Report was provided to administrator Ana Kunz.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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