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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602022
Report Date: 10/09/2023
Date Signed: 10/10/2023 09:11:39 AM

Document Has Been Signed on 10/10/2023 09:11 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HALLDALE MANORFACILITY NUMBER:
198602022
ADMINISTRATOR:BUSTOS, GLENDAFACILITY TYPE:
740
ADDRESS:23438 HALLDALE AVENUETELEPHONE:
(310) 533-7364
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 5DATE:
10/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:EVANGELINE AGATEPTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/9/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiencies visit. LPA Lourdes Montoya met with Back-up Administrator Evangeline Agatep.

During LPA's unrelated complaint visit, LPA observed the following deficiencies:

1. At 10:29 AM, LPA observed the sliding patio door is hard to close and open due to bent or warped rollers/tracks.

2. At 10:30 AM, LPA observed window screens in resident bedroom #4 and staff bedroom and the sliding door screen are not in good repair.

3. At 10:31 AM, LPA observed the gate latches of both side gates are broken.

4. At around 11:09 AM, LPA observed the door in shared residents bedroom #3 does not fully close. LPA noticed the footboard of a bed frame blocks the door and causes the door not to close fully. Per LPA's interview with S3, for about eight months the door has not been closing fully due to the footboard blocking the door.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies have been observed and citations issued (ref. LIC 9099-D).

An exit interview conducted with Evangeline Agatep and a copy of report and appeal rights provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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Document Has Been Signed on 10/10/2023 09:11 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 10/09/2023 at 02:05 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: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2023
Section Cited
CCR
87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement was not met as evidenced by:
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The Back-up Administrator shall rearrange the beds to ensure the door will fully close for resident's privacy. A proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/23/2023.
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During today's visit while LPA Montoya was interviewing R2 at around 11:09 AM, LPA observed the door does not fully close. LPA noticed the footboard of a bed frame blocks the door and causes the door not to close fully. Per LPA's interview with S3, for about eight months the door has not been closing fully due to the footboard blocking the door. This poses a potential risk to resident's health, safety and/or personal rights.
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Type B
10/23/2023
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
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The Back-up Administrator shall repair or replace the window screens, sliding patio door and gate latches. Proof of corrections shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/23/2023.
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During today's visit while LPA Montoya was touring the outside ground of the facility at 10:29 AM, LPA observed the sliding patio door is hard to close and open due to bent or warped rollers/tracks. At 10:30 AM, LPA observed window screens in resident bedroom # 4 and staff bedroom and the sliding door screen are not in good repair. At 10:31 AM, LPA observed the gate latches of both side gates are broken. These pose a potential risk to resident's health, safety and/or personal rights.
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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:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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