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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603599
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:11:38 PM

Document Has Been Signed on 09/07/2023 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MANSA HOMEFACILITY NUMBER:
198603599
ADMINISTRATOR:PERERA, VERONICA & CINDYFACILITY TYPE:
735
ADDRESS:13806 MANSA DRTELEPHONE:
(562) 682-8256
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 1DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Veronica Perera TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced annual visit using the Inspection Tool. LPA met with the Administrator Veronica Perera and the purpose of the visit was discussed.

Structure/Physical Plant: The facility is part of a single story home located in a residential area and contains the following: living room, dining area, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) client rooms, (2) bathrooms for clients; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for client use. A connected garage inaccessible to clients for storage, a washer and dryer. The residence is equipped with air conditioning. Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is a cordless phone for client use. Fire Extinguisher observed Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Knives, cutlery and other sharps inaccessible to clients. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working, all detectors tested and operational. Fire extinguishers observed. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to clients. First aid kit observed. Postings: Required wall postings observed. Residents & Staff Files: LPA reviewed (1) of (1) Client medication records and files , as well as two (2) Staff Files . Emergency Disaster Plan observed. Plan of Operations Observed. Infection Control plan observed

Inspection tool was completed and no deficiencies were observed. Exit interview was conducted, and a Facility Evaluation Report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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