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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320013
Report Date: 06/30/2021
Date Signed: 07/29/2021 09:45:23 AM

Document Has Been Signed on 07/29/2021 09:45 AM - 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
MONTERY PARK, CA 91754
FACILITY NAME:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR:COTY CABRALFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
06/30/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Allaine De LeonTIME COMPLETED:
03:00 PM
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On 6/30/2021 at 2:17 pm, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced case management visit for the Plan of Correction (POC). Upon arrival, LPA Montoya called the facility, spoke with the House Manager (HM) Allaine De Leon and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

LPA Montoya informed HM Allaine De Leon the purpose of today’s visit is to ensure that the deficiencies cited during the Annual Inspection on 6/15/2021 were corrected and in compliance with Title 22 Regulations.

On 6/15/2021, LPA Montoya observed below deficiencies and Title 22 regulations were cited, Proof of Corrections (POCs) were due on 6/21/2021.

1. Section 87555(b)(27) - LPA observed fruit flies inside a kitchen cabinet below the stove and around the kitchen area.
2. Section 87303(a)(1)- The kitchen ceiling, floor, walls, kitchen cabinets, countertop oven and stove top are dirty and greasy.

During today’s visit, LPA did not observe any more fruit flies anywhere inside the facility. LPA also observed the kitchen ceiling, floor, walls, kitchen cabinets, countertop oven and stove top were cleaned and degreased.
Exit interview conducted. A copy of the report and POC letters were provided to House Manager Allaine De Leon.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2021
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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