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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 05/30/2023
Date Signed: 05/30/2023 06:59:46 PM

Document Has Been Signed on 05/30/2023 06:59 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: 86DATE:
05/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Ana Kunz & Dario Esguerra TIME COMPLETED:
04:00 PM
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On 05/30/23, Licensing Program Analysts (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. Upon arrival, LPA conducted a risk assessment. LPA spoke with administrator Ana Kunz who confirmed the facility has no COVID activity. LPA explained the purpose of the visit is to conduct a health and safety inspection.

On 05/29/23, Kunz reported an incident on 05/28/23 that the entire facility evacuated due to a fire in room #113 and adjacent room #112. The location of the fire was in room #113. According to Kunz, the resident left the electric wall heater running unattended. The smoke alarm in room #113 became activated when smoke emanated through the interior walls. The management was alerted of the issue and dispatched 911.

Kunz contacted the local Fire Department and assessed the damages. The areas that were damaged are shared interior walls and both wall heaters for rooms #113 and #112. Room #113 is currently occupied by clients #1- #2 (C1) and (C2). Both clients were not in the room during the incident. There was one client # 3 (C3) in #112 who was in the room during the fire and was able to evacuate timely. All clients were able to evacuate the building at the front in time, according to Kunz. Evacuation did not result in any injuries or relocations.

LPA assessed for damages and observed the interior walls shared in rooms #113 and #112 and both electrical heaters. LPA observed both rooms with operational smoke detectors.

All electrical heaters and wiring will be inspected by the facility, and what needs to be repaired or replaced will be done.

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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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