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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602381
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:52:52 PM

Document Has Been Signed on 10/07/2021 04:52 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:MAGNIFICENT MANORFACILITY NUMBER:
198602381
ADMINISTRATOR:MINDA MCNAMARAFACILITY TYPE:
740
ADDRESS:22831 MADRONA AVENUETELEPHONE:
(310) 326-1617
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 4DATE:
10/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Minda McNamaraTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Case Management - Deficiencies visit and met with administrator Minda McNamara. The purpose of this visit is to cite on deficiencies observed during investigations that were conducted on the complaints with control numbers 11-AS-20200312105209 and 11-AS-20200309132542.

Based on investigations by the departments Investigations Branch (IB), the administrator Rosendo Carlo Miranda retained resident R1 at the facility while having prohibited health conditions.

Record reviews conducted by LPA Coronel indicate that there were no incident reports submitted within seven days of R1's hospitalization's on 02/19/2020 and 02/28/2020.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.

An exit interview was conducted, plans of corrections were discussed. A copy of this report and appeals rights were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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 10/07/2021 04:52 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 10/07/2021 at 11:06 AM
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: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
87405(d)(2)

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Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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The licensee will review Title 22 Regulation 87405(d)(2) Administrator - Qualifications and Duties. Proof of correction will be submitted by POC due date.
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Based on IB's investigation the licensee failed to ensure that the administrator had the knowledge and ability to conform to Title 22 Regulation 87615(a)(1) Prohibited Health Conditions, R1 was retained at the facility while having prohibited health conditions this posed an immidiate health and safety risk to residents in care.
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Type B
10/14/2021
Section Cited
CCR87211(a)(1)(B)

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Reporting Requirements. Each licensee shall furnish to the licensing agency ...following: A written report shall be submitted... within seven days of the occurrence of any of the events... below. This ...case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as
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The licensee will conduct training and review Title 22 Regulation reporting requirment 87211(a)(1)(B) Reporting Requirements. Proof of correction will be submitted by POC due date.
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evidenced by: Based on record reviews the licensee failed to ensure that written reports of serious injuries were submitted within 7 days, R1's hospitalization events were not reported to the department which posed potential health and safety risk to residents 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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021


LIC809 (FAS) - (06/04)
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