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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602864
Report Date: 02/27/2023
Date Signed: 03/13/2023 09:11:36 AM


Document Has Been Signed on 03/13/2023 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SENIOR MANOR CAREFACILITY NUMBER:
198602864
ADMINISTRATOR:STEVEN GRADNEYFACILITY TYPE:
740
ADDRESS:2011 SANTA RENA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gloria Somintac, House ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Gloria Somintac, House Manager and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (4) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room in the attached garage.

LPA and Gloria toured the entire inside of facility. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the hall closet. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. No technical Advisory (TA) issued.

An exit interview conducted with Gloria Somintac, House Manager and a hard copy of report provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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