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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602864
Report Date: 11/17/2020
Date Signed: 11/18/2020 09:40:48 AM

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:SENIOR MANOR CAREFACILITY NUMBER:
198602864
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:2011 SANTA RENA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 5DATE:
11/17/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Gloria Somintac, House ManagerTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martessa Brown conduct an unannounced Health and Safety visit to the above facility in response to an initial complaint tele-visit that was previously conducted on 11/17/2020. LPA met with Gloria Somintac, the House Manager

During todays visit LPA observe the following regarding staff #1 was not associated to the facility while working. Staff #2 was working at the facility during LPA's televisit and not finger print cleared. LPA checked records and confirmed with El Segundo Office the following deficiencies.

During today’s visit the following deficiencies were observed and Civil Penalty was issued:

*Staff #1 were not associated to the facility.
* Staff #2 were not finger print cleared.

Deficiencies cited on California code of regulations title 22, division 6, chapter 8

Exit interview conducted and a copy the report email to administrator for return signature.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE
FACILITY NUMBER: 198602864
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2020
Section Cited

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Criminal Record Clearance:
(e)All individuals subject to a criminal record review... (1) Obtain a California clearance as required by the Department ...
(2) Request a transfer of a criminal record clearance as specified in Section 87355
This requirement is not met as evidence by:
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LPA observed staff #2 Richard Librenbo working at the facility and does not have a finger print clearance. staff #1 Joel Vilar worked at the facility and was not associated to the facility. LPA checked records and also confirmed with El Segundo office. This poses and immediate health and safety risk to all residence at the facility.
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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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2020
LIC809 (FAS) - (06/04)
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