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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607305
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:57:34 PM

Document Has Been Signed on 08/09/2022 02:57 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:CARRILLO MANORFACILITY NUMBER:
197607305
ADMINISTRATOR:ROWENA MARANTAL-CARRILLOFACILITY TYPE:
740
ADDRESS:14006 SYLVANWOOD AVE.TELEPHONE:
(213) 281-1439
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 3DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Rowena CarrilloTIME COMPLETED:
03:02 PM
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
On 8/9/22 at 01:00 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Rowena Carrillo who assisted with today’s visit.

The home is licensed to serve a capacity of six elderly residents age 60 and above, of which all may be non-ambulatory. Bedridden fire clearance approved for bedroom #1 and an approved Hospice Care waiver for two residents at any one given time. The facility is a single-story building in a residential area, with a kitchen, dining room, 2 living room, 4 bedrooms, 2 bathrooms, backyard with shaded area. Fire extinguisher observed kitchen fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.



LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Report continued 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CARRILLO MANOR
FACILITY NUMBER: 197607305
VISIT DATE: 08/09/2022
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
Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The backyard was observed to have a lot of storage materials and debris. Administrator stated it will all be removed in a week. The resident bathrooms are clean, and showers have grab bars and non-skid materials. The hot water temperature measured at 84.3 - 99.3 degrees F, which is not within the required 105-120 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility. Medications reviewed for all clients and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6014763735 expire 3/26/2023. Last emergency disaster drill 2/20/22.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Administrator / Appeal Rights Provided / A Copy of the Report Issued to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/09/2022 02:57 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 08/09/2022 at 02:39 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARRILLO MANOR
FACILITY NUMBER: 197607305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
During the tour of the facility, LPA observed alot of storage materials and debris located in the backyard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2022
Plan of Correction
1
2
3
4
Administrator stated materials will be removed in a week. Administrator will send photo proof to licensing, that shows the clearance of materials by POC date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Water temperature was tested between 84.3-99.3 in both facility bathroom and kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2022
Plan of Correction
1
2
3
4
Administrator will bring water temperature between 105- 120 degrees F. and keep a water temperature log of both bathrooms and send it to licensing by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3