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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609886
Report Date: 01/20/2022
Date Signed: 01/20/2022 12:23:15 PM

Document Has Been Signed on 01/20/2022 12:23 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FRANCES MANOR IFACILITY NUMBER:
197609886
ADMINISTRATOR:PROVOST, EDNA A.FACILITY TYPE:
740
ADDRESS:26167 VIA RAZATELEPHONE:
(323) 919-9331
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 6DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eddie Provost, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Shira Stamps, met with administrator Eddie Provost for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:30 am and was greeted by caregiver Mylyn Streeks. Two (2) residents were observed in the living room watching TV. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting. The Administrator arrived at 10:47 am. LPA informed the Administrator of the purpose of the visit. The Administrator stated she had an appointment later, and caregiver Mylyn Streeks can sign the report.
Infection control: LPA Stamps reviewed facility mitigation plan (approved on 04/21/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitize/wash hands.

A physical plant tour was conducted with Administrator at 10:50 am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying six (6) residents. The facility is Fire Cleared for six (6) non- ambulatory, one of which may be bedridden.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system and it was observed to be operational for each room.

Bathrooms
At 10:58 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 10:58 am and measured within regulation at 119.8 degrees F.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FRANCES MANOR I
FACILITY NUMBER: 197609886
VISIT DATE: 01/20/2022
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Food Inspection
LPA conducted tour at the kitchen around 10:50 am and observed there to be sufficient stock of two day perishables and seven day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. Medications and chemical/hazardous items were observed to be locked.

Physical environment
LPA toured the outside area of the facility at 11:07 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and dual carbon monoxide detectors were tested and observed to be operational at 11:15 am. There are two (2) fire extinguishers, one (1) is located in the kitchen and one (1) is located in the garage. Fire extinguishers were observed to be full and last serviced on 11/20/21. At approximately at 10:55 am, the Resident files and personnel files were observed to be locked in the dining room.

Garage
LPA observed the garage to be attached to the facility and currently being used for extra food storage and the laundry area. LPA observed all chemicals/hazardous items locked and inaccessible to residents in care.

Administrative: LPA reviewed two (2) residents medical documentation and verified a prescription for bed rails was prescribed by their doctors. LPA collected the resident roster and LIC.500. Annual fee is current.


An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC809 (FAS) - (06/04)
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