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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602022
Report Date: 07/15/2022
Date Signed: 07/15/2022 07:15:37 PM


Document Has Been Signed on 07/15/2022 07:15 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
CCLD Regional Office, 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:
07/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Licensee - Glenda BustosTIME COMPLETED:
03:30 PM
NARRATIVE
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On 07/15/2022, Licensing Program Analyst (LPA) Don Senaha conducted a Case Management visit to check on the health and safety of the residents living at the facility. LPA was greeted by Licensee Glenda Bustos and explained the purpose of the visit.

LPA toured the physical plant with caregiver Wilfred Tizon.

There were two (2) deficiencies cited. See LIC 809 D page.

An exit interview was conducted with Licensee Glenda Bustos and a hard copy was provided for signature.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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 2


Document Has Been Signed on 07/15/2022 07:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2022
Section Cited

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above. LPA observed Lysol in the dining area unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
07/18/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above. LPA observed scissors in the kitchen dish rack unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2