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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 12/09/2022
Date Signed: 01/09/2023 07:09:16 AM

Document Has Been Signed on 01/09/2023 07:09 AM - 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: 94DATE:
12/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Mata Fonopo TIME COMPLETED:
03:45 PM
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On 12/09/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent case management visit at this facility. LPA met with assistant administrator Mata Fonopo and explained the purpose of the visit. LPA is to issue the final results of the death investigation of client #1(C1).

During this investigation, LPA interviewed client #2 (C2) roommate, house manager staff #3 (S3), housekeeping supervisor staff #2 (S2), and housekeeper staff #1 (S1) and reviewed the death certificate. The certificate revealed that (C1’s) cause of death on 06/30/22 was Ventricular arrhythmia and Cardiovascular disease.

Based on information gathered, the Department found no evidence of negligence or foul play and will not close this investigation.

An exit interview is conducted with Mata Fonopo and a copy of the report is provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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