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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:19:31 PM

Document Has Been Signed on 10/06/2022 12:19 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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: 90DATE:
10/06/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Ana Kunz & Dario Esguerra TIME COMPLETED:
12:31 PM
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On 10/06/22, Licensing Program Analysts (LPAs) Ernand Dabuet and Mario Leon conducted an unannounced Case Management visit at this facility. Upon arrival, LPA conducted a risk assessment. LPAs spoke with administrator Ana Kunz who confirmed the facility has COVID activity. Kunz states there are (2) residents that are under isolation. LPA explained the purpose of the visit is to conduct a health and safety inspection.

On 10/05/22, Kunz self-reported an incident on 10/04/22 that the entire facility evacuated due to a fire structure. The location of fire structure was in the rear kitchen. According to Kunz, the kitchen staff noticed smoke coming through the walls and alerted management of the issue. Kunz contacted the local Fire Department and assessed the damages. The areas that were damaged are the exhaust hood wall and the room above the kitchen room #214. Room #214 is currently unoccupied. The interior/exterior walls of the kitchen and room #214 were damaged during the emergency response.

After assessing the damages, LPAs observed the wall being constructed. The LPAs observed that all utilities were working. As a result of the evacuation, no residents were injured or relocated.

An exit interview was conducted with Ana Kunz and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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