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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320066
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:58:59 PM

Document Has Been Signed on 04/26/2023 03:58 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
EL SEGUNDO, 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:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Mariel Sheryl Ventura-AdministratorTIME COMPLETED:
04:00 PM
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On 4/26/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced visit to this facility. The purpose of today’s visit was to conduct an Annual Inspection. LPA/Iniguez met with Mariel Sheryl Ventura/Administrator. Facility is licensed for (6) residents (3) non-ambulatory and (3) ambulatory residents. There are (0) residents diagnosed with mild Dementia residing in the facility. There is (1) Hospice resident at the facility. The facility handles residents’ cash resources.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 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/Iniguez inspected the following during visit: documents are posted as mandated. Bedrooms contain the furniture mandated, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including grab bars, and non-skid surfaces mats. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation.

Evaluation Report continues LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MANHATTAN PLACE RESIDENCE INC
FACILITY NUMBER: 198320066
VISIT DATE: 04/26/2023
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Medications are locked, and records are current.
Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked. Manual, smoke, and carbon monoxide detectors were in compliance. The water temperature properly measured between 105F°-120F° degrees (Kitchen 110.3F° & Bathroom #1 112.4F°, Bathroom #2 110.6F°, Bathroom #3 109.8F° ).

fire extinguishers are fully charged, adequate linen supply, the facility telephones are working. All exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered.




LPA conducted a records review of (5) client records, (5) staff records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (5) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.



A copy of the liability insurance and administrator certification will be email to LPA/Iniguez.


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

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator Mariel Sheryl Ventura
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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