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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603798
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:41:26 AM

Document Has Been Signed on 02/06/2025 11:41 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:EVELYN'S MANORFACILITY NUMBER:
198603798
ADMINISTRATOR/
DIRECTOR:
HALLMAN, KAYLONFACILITY TYPE:
740
ADDRESS:1126 E 82ND STREETTELEPHONE:
(310) 739-9303
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 0DATE:
02/06/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Applicant Kaylon HallmanTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a pre-licensing visit. LPA met with applicant Kaylon Hallman. An initial application was submitted to Community Care Licensing Department (CCLD) for a Residential Care Facility for the Elderly (RCFE) to serve 6 non-ambulatory residents in the age range of 60 and over. The fire clearance has been approved for six (6) non-ambulatory residents with one being bedridden in room #4. This property has never been licensed. The physical plant was toured with the applicant. Component III was conducted.

The facility is in a residential area and is a one-story family home. There are four (4) resident bedrooms, two (2) bathrooms, living room, dining area, kitchen, front yard, back yard, and detached garage with office. LPA conducted the tour with Kaylon Hallman and observed the following: Smoke detectors were observed in common areas and in each resident’s bedroom. There are 2 carbon monoxide detectors in hallway. Residents’ bedrooms were observed to have required furniture such as bed frames, dressers, chairs, lamps, and sufficient closet space. The required bedding was also observed. The home has two (2) bathrooms and were clean and sanitary. The water temperate was tested and measured at 108.1 and 105.6 degrees, which is within the required 105-120 degrees. Grab bars and non-slip mats were also observed in bathrooms. There is a fire extinguisher in kitchen. All appliances in kitchen were observed to be clean and operational. The sharp knives are located in the kitchen drawer that is inaccessible to residents. Cleaning supplies and chemicals are stored in a locked cabinet under sink. Medications will be locked in a cabinet in kitchen. The backyard has a shaded area for residents. The home does not have a pool or any large bodies of water. There are cameras only in common areas inside the home. No records were reviewed since the home has never been licensed.

SEE LIC 809 C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EVELYN'S MANOR
FACILITY NUMBER: 198603798
VISIT DATE: 02/06/2025
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The following discrepancies were observed and must be corrected.

#1 Facility will obtain telephone for residents.

#2 Complaint poster PUB 475 will be posted.

#3 Facility will obtain first aid manual.

An exit interview was conducted. A copy of this report was given to Kaylon Hallman.

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

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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