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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320066
Report Date: 09/10/2022
Date Signed: 09/11/2022 08:28:55 AM

Document Has Been Signed on 09/11/2022 08:28 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
MONTEREY PARK, CA 91754
FACILITY NAME:MANHATTAN PLACE RESIDENCE INCFACILITY NUMBER:
198320066
ADMINISTRATOR:PHAN, PAULFACILITY TYPE:
740
ADDRESS:16303 MANHATTAN PLTELEPHONE:
(310) 819-8681
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 6CENSUS: 5DATE:
09/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Hai Nguyen, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Rosanne Germille, Care giver and later met with , Hai Nguyen administrator and the purpose of today’s visit was explained.

There are currently (5) Westside Regional Center consumers in placement. All (3) clients are ambulatory. (2) non-ambulatory. The facility is a single-story brown stucco structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 3 bathrooms, office/living room, kitchen, dining room/laundry area, covered front porch and back porches both with ramps, indoor and outdoor activity area, storage hut, and an attach 2 car garage.

LPA and Rosanne toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 - 4 are occupied by clients and contain the mandated furniture. Bedroom 3 is a staff bedroom. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are inter-connected and in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is current, 1 resident file is current along with medications. The water temperature is at 106.2 degrees. A comfortable temperature is maintained in the facility (70 degrees). Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and sharp knives and/or items are inaccessible to clients, (1) fire extinguishers is fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2022
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MANHATTAN PLACE RESIDENCE INC
FACILITY NUMBER: 198320066
VISIT DATE: 09/10/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors temperatures are checked and logged, sanitizer/soap and paper towels in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, clients rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, No fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for clients to use, clients temperatures are checked and logged (once a day). Emergency contacts updated and posted, and PPE's are enough for 30 days.

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

Technical Advisory (TA) issued:


1. No fit testing done for staff member.

An exit interview conducted with Paul Phan, Administrator

Due to technical difficulties (printer not working), copy of report and TA will be provided via email

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2022
LIC809 (FAS) - (06/04)
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