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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320096
Report Date: 07/24/2025
Date Signed: 07/24/2025 04:10:23 PM

Document Has Been Signed on 07/24/2025 04:10 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRICKSTONE MANORFACILITY NUMBER:
198320096
ADMINISTRATOR/
DIRECTOR:		DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:20551 MADISON ST.TELEPHONE:
(310) 251-2382
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator - Bryan BernardinoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 07/24/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Bryan Bernardino. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 6 bedridden adults ages 60 and above. The facility has an approved hospice waiver for 6 residents.

A total of 5 residents are currently residing in this facility.

The Annual Licensing Fees are current.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/24/2025 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 07/24/2025 at 03:05 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: BRICKSTONE MANOR
FACILITY NUMBER: 198320096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 3 out of 5 residents not having complete and current records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
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2
3
4
The Administrator has agreed to email resident records to Socorro.Leandro@dss.ca.gov.
Resident 2: Physicians Report, Preplacement Appraisal Information, Tuberculosis Test Results (included in Physicians Report), Personal Rights (LIC613C), Safeguards for Property/Valuables.
Resident 3 & Resident 4: Appraisal & Needs Services Plan (LIC625).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 07/24/2025
NARRATIVE
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Facility Layout: The facility is a one-story house located in a residential street. The home consists of 6 resident bedrooms, 1 staff bedroom, 4 full bathrooms, 1 kitchen, 1 dinning room area, 1 living room area, 1 attached garage, 1 front yard patio area, 1 backyard patio area with shaded seating.

Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is a fire extinguisher in the kitchen area, and it was last serviced on 04/14/2025. There is a landline phone in the kitchen.

Living Room: There are games/activity work (i.e. board games and books) for residents in the living room area. There are couches and chairs for residents to sit at.

Resident Bedrooms: 5 out of 6 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 07/24/2025
NARRATIVE
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Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. The hot water temperature measured between 102 Fahrenheit to 110 Fahrenheit.

Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 5 out of 5 resident Medication Administration Records (MARs) were reviewed and they were current and up to date.

Garage: is used as a storage room and extra facility food and supplies are kept in the garage.

Miscellaneous: Documents are posted as mandated. Last fire drill was conducted on 07/2025. The first aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a videoconferencing device in the facility for resident use.

5 staff records were reviewed, 5 out of 5 staff records have required criminal record clearance. 2 out of 5 staff records were not complete and current by not having the health screening report, training's, and current first aid certificate.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 07/24/2025
NARRATIVE
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5 resident records were reviewed, 3 out of 5 resident records were not complete and current. Resident 2 did not have: Physicians Report, Preplacement Appraisal Information, Tuberculosis Test Results, Personal Rights, and Safeguards for Property/Valuables. Resident 3 and Resident 4 did not have an updated Appraisal within the 12 months.

A technical violation is being provided regarding maintaining complete and current staff records in the facility.

A deficiency is being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding maintaining complete and current resident records in the facility.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Bryan Bernardino.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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