198601766-5-20-2023-11-AS-EDAT-CRZTU6-20230520150148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 05/20/2023
Date Signed: 05/20/2023 03:02:50 PM

Document Has Been Signed on 05/20/2023 03:02 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 MANOR		FACILITY NUMBER:	198601766
ADMINISTRATOR:	KUNZ, ANA		FACILITY TYPE:	735
ADDRESS:	21515 S. FIGUEROA STREET		TELEPHONE:	(310) 328-5116
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 110		CENSUS: 85	DATE:	05/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Ana Kunz & Hector Jimenez		TIME COMPLETED:	02:53 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/20/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the 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 rooms and (55) restrooms, (2) activity rooms, (1) dining area, (1) commercial kitchen, and (1) courtyard patio area. LPA toured the physical plant with Dario Esguerra. 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. The client's rooms were inspected: #106, #107, #108, #110, #118, #206, #211, #214, #214, #226, and #230. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.0 – 112.1 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be sanitary and appropriately furnished at the time of the 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 and maintained properly. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Fire, Disaster, and Evacuation Drills was completed on 05/05/23. A working landline phone is available at the front desk. (Evaluation Report continues on LIC 809-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 05/20/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA conducted an audit of client #1-#5 (C1-C5) service files, and staff #1-#5 (S1-S5) personnel files were in order and complete. LPA conducted (4) client and (4) staff interviews.

DEFICIENCIES:
LPA observed rooms #122 and #228 with no window screens.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiencies have been observed and citations issued (ref. LIC 809-D).

An exit interview was conducted with Ana Kunz and a copy of the report and appeal rights were provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/20/2023 03:02 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 05/20/2023 at 01:20 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
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above. LPA identified (2) room with no window screens #122 and #228. This violation which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will adhere to Title 22 80087 and ensure the window screens are replace/repaired. Proof of correction must be sent by fax at 323-981.1781 by POC due date: 05/27/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Ernand Dabuet

LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3