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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320066
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:28:44 PM

Document Has Been Signed on 04/27/2023 01:28 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:
04/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Mariel Sheryl Ventura-Administrator TIME COMPLETED:
01:30 PM
NARRATIVE
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On 4/27/2023 at 11:24AM, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management – Deficiencies visit to Manhattan Place Residence INN. LPA met with Mariel Sheryl Ventura /Administrator and the purpose of the visit was explained.

On 4/26/2023 LPA Iniguez conducted an unannounced Annual Inspection and found out the facility has 1 hospice patient. LPA asked for proof of hospice waiver, but administrator told LPA she will send proof by email on 4/27/2023. On 4/27/2023 LPA received by email a letter request for hospice waiver dated on 8/8/2019. After reviewing this document, the facility history profile and talking with LPM Alvarez, LPA Iniguez will render a citation for the following:

87632 (a) Hospice Care Waiver

In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility.

Exit interview conduct, appeal rights discussed and a copy of this report and appeal rights provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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Document Has Been Signed on 04/27/2023 01:28 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 04/27/2023 at 01:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MANHATTAN PLACE RESIDENCE INC
FACILITY NUMBER: 198320066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
87632(a)

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87632 (a) Hospice Care Waiver
In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility.
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Licensee will adhere to Title 22 87632 regulations and will ensure to request a Hospice Waiver with CCLD. Licensee will ensure to provide proof of correction sent by email to LPA.
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This requirement is not met as evidence by:
Based on facility inspection. This violation possess a potential Health and Safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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