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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603599
Report Date: 07/26/2024
Date Signed: 07/26/2024 11:12:21 AM

Document Has Been Signed on 07/26/2024 11:12 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MANSA HOMEFACILITY NUMBER:
198603599
ADMINISTRATOR/
DIRECTOR:		PERERA, VERONICA & CINDYFACILITY TYPE:
735
ADDRESS:13806 MANSA DRTELEPHONE:
(562) 682-8256
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Administrator Veronica PereraTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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 (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Veronica Perera at approximately 8:54 AM and explained the reason for the visit.

The home is licensed to serve up to (4) four ambulatory clients ages 18 - 59. The facility is a single-story home located in a residential neighborhood, contains a total of four (4) client bedrooms, two (2) common bathrooms, a living room/activity room, kitchen, dining area, laundry area, medication area, and attached garage.



LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has two (2) fully charged fire extinguishers which is kept in the kitchen and hallway. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage area next to the entrance of the facility. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked in a box and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has one large refrigerator.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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 3
Document Has Been Signed on 08/07/2024 11:38 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/29/2024 08:56 AM


Created By: Christian Gutierrez On 07/26/2024 at 10:47 AM
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MANSA HOME
FACILITY NUMBER: 198603599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two (2) out of four (4) clients physicians reports were not in files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
1
2
3
4
Administrator will obtain physicians reports and email to LPA.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above facility did not have fire/earthquake drill training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
1
2
3
4
Administartor will conduct training and will send training log to LPA via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MANSA HOME
FACILITY NUMBER: 198603599
VISIT DATE: 07/26/2024
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
26
27
28
29
30
31
32
Five (5) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) Client files were reviewed and two (2) out of four (4) included physicians report, TB clearance, and individual program plan (IPP)report. No fire/earthquake drill was conducted deficiency cited. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in living room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Veronica Perera

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3