198603599-9-8-2022-28-AS-YTYG-CJ3P27-20220908105529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603599
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:55:41 AM

Document Has Been Signed on 09/08/2022 10:55 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:	MANSA HOME		FACILITY NUMBER:	198603599
ADMINISTRATOR:	PERERA, VERONICA & CINDY		FACILITY TYPE:	735
ADDRESS:	13806 MANSA DR		TELEPHONE:	(562) 682-8256
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 4		CENSUS: 0	DATE:	09/08/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Applicants-Vernonica Perera & Cindy Ramos		TIME COMPLETED:	11:15 PM

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Licensing Program Analysts (LPAs) Ya-Ting Yang and Jose Villalobos conducted an announced pre-licensing visit. LPAs met with the Applicants Cindy Perera and Veronica Perera for the purpose of conducting a pre-licensing inspection. Licensee / Perera Home Care, INC has submitted an application to operate an Adult Residential Facility for a capacity of four (4) residents, ages 15 to 59. The facility has an approved fire clearance for four ambulatory residents. Fire clearance was granted on 8/4/22. The new application is being processed as an initial license. There are currently no (0) clients living at the facility.

LPAs toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is located in a residential neighborhood. The facility consists of a main floor. A tour of the main floor includes four (4) client bedrooms, two (2) common bathrooms, a living room/activity room, kitchen, dining area, laundry area, medication area, attached garage, no private bathrooms observed.

LPAs observed a fully equipped living room and a dining area with sufficient dining capacity. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all functional. The supply of dishes/cups was adequate. During today's visit, LPAs observed an appropriate food supply of two (2) days of perishables, seven (7) days of non-perishables, and additional food and water for emergency use in the cabinet. Client bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Client bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each client. The bathrooms were clean, operational with non-skid mats, and equipped with paper towels.

Continue on LIC809-C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: YaTing Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MANSA HOME	FACILITY NUMBER: 198603599
	VISIT DATE: 09/08/2022

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LPAs observed three (3) fire extinguishers throughout the facility full charged and in compliance. The facility is equipped with a centralized sprinkler system. The facility has a central heating system and individual AC units inside resident bedroom.

Medications and First Aid Kit were centrally stored and locked in the medication cabinet, making inaccessible to unauthorized persons at all times. First aid kit was fully stocked with a manual. Client and staff records are centrally stored and remained accessible only to the authorized staff. Clients P&I monies will be centrally stored and locked in the business office. All sharp objects, knives, and cleaning supplies were locked in the kitchen cabinet, making it inaccessible to clients. The carbon monoxide& smoke detectors combo were observed and tested throughout the facility. There was a functioning telephone on the premises. The hot water temperature was tested throughout the facility between 105 degrees to 120 degrees Fahrenheit in compliance with Title 22 Regulation. All toxins such as cleaning solutions and detergent soap were also locked in the storage room. There was no pool or other bodies of water. LPAs also observed the Emergency Disaster Plan, Personal Rights and Facility Sketch posted inside the facility as mandated by Title 22 Regulations.

Component III was conducted during this visit. LPA used the inspection tool and the pre-licensing checklist for an Adult Residential facility during this visit. Physical plant is cleared at the time of the visit.

An exit interview was conducted and a copy of this report was provided to the applicants.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: YaTing Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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