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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203284
Report Date: 08/24/2022
Date Signed: 08/24/2022 06:30:07 PM

Document Has Been Signed on 08/24/2022 06:30 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MICHAEL'S MANORFACILITY NUMBER:
198203284
ADMINISTRATOR:PHILIP JOHN ROMEROFACILITY TYPE:
740
ADDRESS:23704 HYNFORD PLACETELEPHONE:
(310) 539-5502
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 5DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Reynaldo Rebebes/caregiver - TIME COMPLETED:
03:15 PM
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On 08/24/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with caregiver Reynaldo Rebebes and was later joined by Licensee Zenaida Macapobre and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory resident ages 60 and over and may retain three (3) hospice residents.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms, one (1) staff room, two (2) bathrooms, one (1) living area, a dining area and kitchen. There is an outside covered patio area in the backyard for seating and a shaded gazebo area in a fenced front yard with a table and ample seating. The laundry area is located in the garage. The garage is attached but only accessible from the side door in the front or the front door of the garage. The garage is also used as storage and has a second refrigerator and freezer for additional food storage.


LPA and caregiver toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature met Title 22 standards in the bathrooms and kitchen sink and measured between 109.0 F and 109.3 F. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MICHAEL'S MANOR
FACILITY NUMBER: 198203284
VISIT DATE: 08/24/2022
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There are two (2) fire extinguishers fully charge located in the kitchen area and the hallway leading to the rooms. Smoke detectors and carbon monoxide were operable and in working condition. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate.


During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken upon entry to the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). There is a fully stocked first aid kit in the medication cabinet. Last fire drill was conducted on August 4, 2022.


No deficiencies were cited during this inspection visit.


An exit interview was conducted and a copy of this report was provided to Administrator Zenaida Macapobre.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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