<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603564
Report Date: 03/07/2023
Date Signed: 03/07/2023 11:55:57 AM


Document Has Been Signed on 03/07/2023 11:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MANSION AT WESTLAKEFACILITY NUMBER:
198603564
ADMINISTRATOR:PUNO-RIVERA, CARMANCITAFACILITY TYPE:
740
ADDRESS:1223 SOUTH ALVARADO STREETTELEPHONE:
(818) 804-0822
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:0CENSUS: DATE:
03/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Judy Agabin - Person in ChargeTIME COMPLETED:
12:00 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
Licensing Program Analyst(s)(LPA) Mary Flores, Erik Zaragoza and Adult Protective Services (APS) Jocelyn Mantuno conducted an unannounced case management visit at the facility. LPAs met with Judy Agabin Person in charge and explained the reason for the visit.

The visit consisted of the following:
  • LPAs toured the homes' bedrooms and a total of 14 beds continue to be occupied.
  • LPAs observed a total of 12 individuals of which 5 individuals need care and supervision.
  • Three (3) people have gone out to the hospital. Resident #14(R14) left to the hospital on 2/17/23. Resident #7 (R7) and #15 (R15) went to the hospital on 3/1/23.
  • During the visit conducted on 2/15/23 (8) eight people were identified that needed care and supervision.
  • (1) individual left the facility on 2/15/23 and (2) were determined to be independent after today's interviews.
  • Today's visit determined there are 5 individuals that must be relocated due to need of care and supervision.
  • Notice of denial of application was emailed and certified mail on 3/1/23.
  • Application to become a licensed facility was denied as of 3/1/23. Per Title 22 Regulations 87768(a)(2)(A) A penalty of $100 per day per resident shall be assessed for the operation of an unlicensed facility under either of the following conditions: (2) Unlicensed operation continues after denial of the initial application. (A) Notwithstanding any appeal action, facility operation must cease within 10 calendar days of the mailing of the notice of denial or upon receipt of the denial notice by the operator, whichever occurs first.
  • At this time operator cannot accept any new residents that require care and supervision and all residents that require care and supervision should be relocated within 10 days of the notice of denial.
  • Civil penalties will be issued if resident's are not relocated by 3/10/23.

Exit interview was conducted with Judy Agabin Person in Charge and a copy of this report and confidential name list (811) were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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 1