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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601899
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:50:36 PM


Document Has Been Signed on 09/30/2024 02:50 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:JEFFERSON MANORFACILITY NUMBER:
198601899
ADMINISTRATOR:CZARINA DOROTANFACILITY TYPE:
740
ADDRESS:1662 W. JEFFERSON BLVD.TELEPHONE:
(213) 880-5505
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:6CENSUS: 3DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Czarina Serrano-AdministratorTIME COMPLETED:
03:05 PM
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On 09/30/24, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Caregiver, Irene Leonor, and explained the purpose of today’s visit. Facility’s Administrator, Czarina Serrano, later joined LPA for the inspection. The facility is licensed to operate for six (6) elderly adults ages 60 and above. Four (4) ambulatory, and two (2) non-ambulatory. Currently there are three (3) residents in the facility.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four bedrooms, two (2) bathrooms, a living room, dining room, kitchen, behind the home there is an office, bathroom, staff room and a laundry area.

LPA and Czarina Serrano toured the inside and out of the physical plant. There were no bodies of water or obstructions on the premises. Exits/ Walkways around the facility were free of debris and hazards. All resident rooms were inspected. Bedrooms had the required furniture and in good condition, adequate lighting was observed, and sufficient closet/drawer space to accommodate the client comfortably. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational and found to be within Title 22 regulations. The water temperature properly measured between 105.0 F and 120.0 F. A comfortable temperature was maintained in the facility.

The kitchen was inspected and there is sufficient perishable and non-perishable food supply and maintained adequately. Sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors and carbon monoxide were tested and are working properly. Fire extinguishers were fully charged. A stocked First Aid kit along with manual was available.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: JEFFERSON MANOR
FACILITY NUMBER: 198601899
VISIT DATE: 09/30/2024
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A review of (3) resident service files and (3) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility.

LPA did not observe any deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the report was provided to Czarina Serrano, Administrator.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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