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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191671691
Report Date: 07/21/2025
Date Signed: 07/21/2025 03:13:42 PM

Document Has Been Signed on 07/21/2025 03:13 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CROFTON MANOR INNFACILITY NUMBER:
191671691
ADMINISTRATOR/
DIRECTOR:		AMALIA ESQUIVIASFACILITY TYPE:
740
ADDRESS:1950 E. 5TH ST.TELEPHONE:
(562) 437-0093
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY: 213CENSUS: 113DATE:
07/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH: Amalia Esquivias, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 07/21/2025 at 8:30am Licensing Program Analyst (LPA) Zina Brown, Lizeth Villegas and Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Amalia Esquivias, Administrator, and Francisca Vallejo, Assistant Administrator and explained the purpose of today’s visit. The facility is licensed to serve resident age 60 & above and cleared to serve 213 non-ambulatory. Currently, the facility has 113 residents. The facilities annual fees are current.

The facility has a current administrator certificate (#7001780740) for Amalia Esquivias valid from 08/21/2023 - 08/20/2025. The facility has liability insurance with Crum & Forster Specialty Insurance (NAIC# 44520) with each occurrence at $2,000,000 and general aggregate at $20,000,000 (policy #PKG101882) effective date 12/31/2024 - 01/01/2026.



The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (107) residents' rooms and bathrooms, (6) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, outdoor patio with umbrella, table, and chairs.

Between the hours of 10:05am - 2:15pm, LPA conducted a records review of (10) resident records, (10) staff records, and the facility disaster plan was current (last updated on 03/05/2025) and in compliance with Title 22 regulations at the time of visit. All resident & staff records were complete. Between the hours of 11:00am - 11:30am, LPA Iniguez conducted (7) Resident Medication Administration Records did not observe any discrepancies at the time of visit.

Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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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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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CROFTON MANOR INN
FACILITY NUMBER: 191671691
VISIT DATE: 07/21/2025
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Between the hours of 9:24am - 10:00am, LPA Villegas and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Five rooms per floor were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for residents’ personal belongings is available. In the dementia unit, the resident have auditory alarms located on outside patio doors. Between the hours of 2:30pm - 2:40pm, LPA Iniguez tested the water in six of the residents rooms and the water temperature properly measured between 105°F -120°F (113.0 °F)

All rooms had the required furniture. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature in each bathroom per room inspected were found to be within Title 22 regulations. LPA observed the facility to have a first aid kits, manual, and emergency supplies. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary, well maintained, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were stored and accessible to residents. The commercial kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. LPA observed the kitchen area to be clean and free from pests. The facilities fire extinguishers were checked and found to be fully charged and accessible; and last serviced on 09/20/2023. All exit doors in the facility have alarm systems. The facility has hardwired and battery-operated smoke and carbon monoxide detectors and are in working condition. A working landline telephone remains available. The last fire drill was conducted 07/13/2025.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe a deficiencies, therefore no citations were issued at this time.

Exit interview was held and a copy of the Facility Evaluation Report was provided to Amalia Esquivias, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
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