198603991-5-7-2026-28-AS-EZAA-DTUQCT-20260507120340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603991
Report Date: 05/07/2026
Date Signed: 05/07/2026 12:04:04 PM

Document Has Been Signed on 05/07/2026 12:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MANSA ROSE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	198603991
ADMINISTRATOR/ DIRECTOR:	FIGUEROA, MANUEL		FACILITY TYPE:	740
ADDRESS:	14233 MANSA DR		TELEPHONE:	(562) 652-4070
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 6		CENSUS: 0	DATE:	05/07/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Manuel Figueroa - Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:18 PM

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Licensing Program Analysts (LPA) Erik Zaragoza conducted an announced Pre-Licensing visit at the facility. LPA met with Manuel Figueroa, Licensee and Administrator for the facility, and explained the purpose of the visit. This Pre-Licensing inspection is being conducted as an initial application to be licensed.

The facility has an approved fire clearance to serve six (6) ambulatory clients. The facility is a single-story home located in a residential neighborhood in the city of La Mirada. The facility consists of a dining room, a living room, kitchen, three (3) shared resident bedrooms, one (1) staff restroom, one (1) client restroom which had a hot water temperature of 116.2 degrees Fahrenheit, a back yard with shaded area, and a detached garage which contains the chemicals for the facility as well as the washer and dryer.

The following was inspected during the evaluation with the Administrator and determined to be compliant with Title 22 Regulations. A locked storage area for central storage of medications was observed in the kitchen. Cleaning supplies are kept separate from food supplies and are stored in the locked in the garage of the facility. The walls, ceilings, floors, areas around the facility were clean and in good repair, however Bedroom #3 is missing a window screen. Two (2) fire extinguishers are located in the facility. The carbon monoxide and smoke detector was observed to be operational. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back areas of the facility were observed to be clean and free of debris. \An operating telephone was observed on the premises, which is easily accessible and available for resident use. The first-aid kit was reviewed and is kept locked in a main hallway of the facility. Activities were observed to be available for the clients as well. Licensee does need to acquire liability insurance as well.

LPA requested that a window screen be installed in Bedroom #3 and liability insurance is obtained and submitted to LPA by email before license is issued. COMP III presentation was held with licensee. Exit interview held and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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