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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603171
Report Date: 01/27/2022
Date Signed: 01/27/2022 04:11:28 PM

Document Has Been Signed on 01/27/2022 04:11 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
MONTERY PARK, CA 91754
FACILITY NAME:EILAT'S MANOR IIFACILITY NUMBER:
198603171
ADMINISTRATOR:NAHUM, EILATFACILITY TYPE:
735
ADDRESS:1623 SHERBOURNE DRTELEPHONE:
(310) 309-0405
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 3DATE:
01/27/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Satria Dana-StaffTIME COMPLETED:
04:20 PM
NARRATIVE
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On 1/27/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management - health checks visit to the above-named facility and met with staff Satria Dana. LPA explained the purpose of the visit and was allowed access to the facility. Administrator was called and informed that LPA had arrived.

The home consists of 4 client bedrooms, 5 bathrooms, living room, dining area and kitchen.

This facility is licensed to serve developmentally disabled adults ages 18 – 59 years: fire clearance was approved for five (5) non-ambulatory clients and one (1) bedridden client. A total of 3 clients are currently residing in this facility. A total of 2 staff and 2 clients were present during this inspection.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients.

4 out of 4 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Bathroom water temperature was between 105F and 120F. Adequate lighting and toiletries accessible to clients. This facility provides clients with hygiene products such as soap, toilet paper, toothbrushes, toothpaste and combs.

LPA observed supplies of nonperishable foods for a minimum of one week. Stove and lights in kitchen where in good operating condition.



LPA observed that medications were safe, locked and inaccessible. Documents are posted as mandated. First aid kit is fully stocked.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapters 1 and 6.

An exit interview was conducted, and appeal rights were discussed with House Manager Naome Leibov

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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 4
Document Has Been Signed on 01/27/2022 04:11 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 01/27/2022 at 12:58 PM
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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited
CCR
80075(b)(5)(A)

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Health Related Services
There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e)...
This requirement is not met as evidenced by:
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Licensee will obtain a written order from physician for PRN medications used by C1 or properly dispose of the PRN medications and submit proof of correction to CCLD office via fax by POC due date.
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At 10:56am LPA noted unlabeled cough syrup and pain reliver in cabinet were for C1, , which are not labelled nor was a physician’s order found. This is an immediate health and safety violation to the residents in care.
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Type A
01/28/2022
Section Cited
CCR80075(b)(5)(B)

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Health Related Services
Once ordered by the physician the medication is given according to the physician's directions.
This requirement had not been met as evidenced by:
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Licensee will ensure expired medications are destroyed properly and get new prescribed medications for C1. Proof of correction will be submitted to CCLD office via fax by POC due date.
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At 10:54am LPA noted that the medications for C1 are expired. This poses and immediate health and safety risk to clients 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 Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/27/2022 04:11 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 01/27/2022 at 03:22 PM
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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited
CCR
80075(b)(k)(5)

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Health Related Services
Each client's medication shall be stored in its originally received container.
This requirement has not been met as evidenced by:
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Licensee will ensure medications are destroyed as they are contaminated and purchase new medications for all three clients. Proof of correction will be submitted to CCLD to office via fax by POC due date.
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At 10:46AM LPA Cifuentes noted medications for C1-C3 had been removed from original container. This poses an immediate health and safety risk to clients in care.
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Type A
01/28/2022
Section Cited
CCR80887(g)

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Buildings and grounds
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement has not been met as evidenced by:
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Licensee will store cleaning solutions and disinfectants in a locked area inaccessible to clients and submit proof of correction via fax to CCLD office via fax by POC due date.
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At 10:45am LPA Cifuentes observed that cleaning solutions in lower kitchen cabinets were not locked. This poses an immediate health and safety risk to clients 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 Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/27/2022 04:11 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 01/27/2022 at 03:25 PM
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
MONTERY PARK, CA 91754

FACILITY NAME: EILAT'S MANOR II
FACILITY NUMBER: 198603171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited
CCR
80087(a)

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Buildings and grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement has not been met as evidenced by:
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Licensee will repair holes and fixtures in bedroom 1, bathroom 1, and add smoke detectors to bedrooms 3 and 4 and submit proof of correction to CCLD office by POC due date.
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At 11:01am LPA saw holes in the walls of bedroom 1 and broken fixtures in bathroom 1 and at 11:17 am LPA noted that bedrooms 3 and 4 have no smoke detectors. This poses and immediate health and safety risk to clients in care.
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Type B
02/10/2022
Section Cited
CCR80072(a)(2)

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Personal Rights
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by:
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Licensee will make non-perishable foods available to clients in care and submit proof of correction to CCLD via fax by POC due date.
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LPA did not find any fruits, vegetables or other non-perishable foods in facility kitchen. This is a potential health and safety risk to the clients 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 Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4