198602381-1-12-2024-11-AS-WGIS-CZET4C-20240112132343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602381
Report Date: 01/12/2024
Date Signed: 01/12/2024 01:23:49 PM

Document Has Been Signed on 01/12/2024 01:23 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MAGNIFICENT MANOR		FACILITY NUMBER:	198602381
ADMINISTRATOR:	MINDA MCNAMARA		FACILITY TYPE:	740
ADDRESS:	22831 MADRONA AVENUE		TELEPHONE:	(310) 326-1617
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 5	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Joseph Sol		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/12/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above using the full CAREs tool. LPA met with Licensee, Joseph Sol, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) non-ambulatory clients, age sixty (60) and over, of which four may be bedridden, with a hospice waiver of four (4). There are currently five (5) residents residing in the facility. Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) bathrooms, living area, dining area, kitchen and outside covered patio area with a table and chairs. There is a detached garage which is used for storage. The garage consists of the washer and dryer for laundry. There were no bodies of water on the premises. LPA observed all walkway outside of the home to be clean, clear, and free of obstructions, hazards, and debris. Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. LPA observed all bedrooms to have the required furniture, including bed(s), dresser(s), nightstand(s), chair(s), and ample storage space for resident’s personal belongings. LPA observed the beds have the required linens, including a mattress cover, fitted sheets, blanket, comforter, and pillows. All bedrooms were observed with ample lighting. LPA observed an ample supply of bed linens, blankets, and comforters stored in the hall cabinet, in good repair. Bathrooms LPA inspected both bathrooms and found them to be within Title 22 regulations and were clean and operational. LPA observed showers had a non-skid mat and secured safety handrails. LPA observed an ample supply of towels, hand towels, and wash cloths in the hall cabinet, in good repair. LPA observed resident’s hygiene boxes and an additional supply secured in a locked cabinet in the bathroom and are inaccessible to residents. The water temperature measured 115.1-degrees and 115.6-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed an ample supply of cookware, dining ware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply on non-perishable foods properly stored, packaged, and labeled. An additional supply of canned foods and a freezer were observed in the garage. Continued on LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MAGNIFICENT MANOR	FACILITY NUMBER: 198602381
	VISIT DATE: 01/12/2024

NARRATIVE

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LPA observed all cleaning supplies secured in a locked cabinet under the kitchen sink. All knives and sharps were observed secured in a locked drawer in the kitchen. The water temperature measured 109.2-degrees Fahrenheit.
Common Rooms LPA observed the facility to be sanitary and appropriately furnished at the time of visit. LPA observed games and activities stored in a cabinet in the living room. LPA observed all rooms and hallways had ample lighting. LPA observed all walkways and hallways to be clean, clear, and free of debris, obstructions, and hazards. The facility was maintained at a comfortable temperature.
Safety LPA observed smoke detectors and carbon monoxide were operable. LPA observed a fully charged fire extinguisher last serviced on 07/08/23. A Fire Prevention Inspection was last conducted on 02/02/23, by the Torrance Fire Department. The last emergency drill was conducted on 12/15/23. LPA observed all exits clearly marked. The facility has a working landline telephone. LPA reviewed and received a copy of liability insurance through Allied Health that is valid till 03/06/24. LPA inspected the First Aid Kit and found it contained the required items and a manual.
Files & Interviews LPA reviewed five (5) resident files and found they contained the required documents. During interviews with residents, they were happy with the services they receive at the facility. LPA reviewed the Administrator and three (3) staff files and found they contained the required documents, training, and certification. During interviews with staff, they were able to answer questions regarding policy and procedure, and resident care and rights. LPA observed all mandated signs and documents posted throughout the facility.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet in hall. All medications were observed in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for three (3) residents. LPA observed resident’s MARs and medication are consistent with properly documented records.
Infection Control During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated infection control signs were posted throughout the facility.

LPA did not observed or cite any deficiencies.

An exit interview was conducted with Licensee, Joseph Sol, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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