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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320326
Report Date: 11/02/2022
Date Signed: 11/02/2022 03:54:41 PM

Document Has Been Signed on 11/02/2022 03:54 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MANNY'S CARE FACILITYFACILITY NUMBER:
198320326
ADMINISTRATOR:NAHUM, MANACHAFACILITY TYPE:
740
ADDRESS:1782 S SHERBOURNE DRIVETELEPHONE:
(310) 309-0405
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 0DATE:
11/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Manager, Eilat NahumTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Antonia Alvizar conducted an announced visit to the above facility for the purpose of a pre-licensing evaluation. LPA met with Manager, Eilat Nahum and explained the purpose of the visit. During the inspection LPA toured the inside and outside of the facility and verified the address of the location.
An application was submitted to Community Care Licensing Division (CCLD) on 09/01/2022 for an initial application for a Residential Facility for the Elderly. The total requested capacity is for 6 clients. Facility has a fire clearance dated on 07/13/2022 for, four (4) ambulatory and two (2) non-ambulatory.
Structure: Facility is a 1- story house located in a residential neighborhood. The facility has 3 resident-bedrooms, (all rooms are double occupancy). Upon entry, there is a living room, and dining room to the right. Through the hallway on the left side is bedroom #1 (Not approved for sleeping/ clients), next kitchen, bedroom #2. At the end of the hallway is bathroom #1, on the right side of the hallway is washer/ dryer hooks. Turning to the right on the hallway is bedroom #3 then bedroom #4 with bathroom #2. There is a 1-car detached garage, with a long driveway. There is a large backyard next to the detached garage. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA observed four (4) cameras inside facility (Command Areas), three (3) cameras outside facility, one (1) camera and the recording cameras display is in the garage. LPA did not observe a hazard such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility.

Bedrooms: All three (3) residents bedrooms have over- head lighting, drawers and/ or closets. The beds, night stands, and chairs will be moved from previous facility. The closets and drawers comply with the requirement of 8 cubic feet of space.


Office: Facility has a large office space located in the detached garage where staff records and client records will be kept locked.

cont. on 809C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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: MANNY'S CARE FACILITY
FACILITY NUMBER: 198320326
VISIT DATE: 11/02/2022
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Residents & Staff Files: Records of clients will be stored in detached garage office space.

Reading Material, Games, Equipment & Materials: The facility has recreational materials for the resident’s use.

Pool/Jacuzzi & Pets: LPA did not observe a pool or jacuzzi on facility grounds. No pets observed.

Fire clearance: Fire Clearance was approved on 09/20/2022 for four (4) ambulatory and two (2) non- ambulatory. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits.

Bathrooms: Facility has two (2) bathrooms. All bathrooms were observed to have a working toilet, and wash basin. All stand up showers and bathtubs were observed in working order.

Linens & Hygiene Supplies: LPA observed pillowcases, mattress pads, fitted sheets, blankets and bedspreads bagged in the washer/dryer space. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash cloths where observed and will be move from previous facility. Facility provides hygiene supplies to residents and LPA observed an adequate supply and will be move from previous facility.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a dedicated landline was observed at previous facility. Line was called by LPA and it is operational. Emergency Disaster Plan and "See Something, Say Something, Let Us Know" was observed posted at previous facility. LPA observed 2 fully charged fire extinguishers throughout the previous facility. One in the kitchen and one in the hallway. These items mentioned will be moved from previous facility.

Food Service: LPA observed dishes, cups and utensils are stored in the kitchen cupboards. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Food supply was adequately stored in kitchen refrigerator, cabinets, and pantry, inspected and observed at previous facility and will be moved.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 3 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: MANNY'S CARE FACILITY
FACILITY NUMBER: 198320326
VISIT DATE: 11/02/2022
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Smoke Detectors: Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Detectors are not connected to any security alarm systems which will notify the fire department in the event of a fire. Facility will be required to call emergency services in the event of an emergency.

Appliances: Stove burners, oven, microwave, refrigerator, and dishwasher are in working order. LPA observed kitchen cabinets locked.



Toxins: Locked/stored in kitchen cabinet at previous facility will be moved.

Medications, First-Aid Kit & Book: Area for medication storage is in a cabinet in the kitchen. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to residents at previous facility and will be moved.

Component III: Conducted at the Pre-Licensing visit, on 11/02/2022 at Manny’s Care Facility.

During the Pre-Licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and Proof of Correction shall be submitted to the CCLD office to the attention of LPA:

· Hot water heater adjusted to deliver hot water between 105F and 120F.

During the visit LPA observed plumber arrive to facility and adjusted the water heater but NOT delivering hot water between 105 F. and 120 F.

Pre- Licensing is INCOMPLETE with deficiency to be resolved by 11/04/2022. A follow up Pre- Licensing LIC 809 will be generated upon resolution of deficiency.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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