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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601899
Report Date: 10/07/2021
Date Signed: 10/29/2021 03:58:46 PM

Document Has Been Signed on 10/29/2021 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:JEFFERSON MANORFACILITY NUMBER:
198601899
ADMINISTRATOR:JOSEFINA GUIAOFACILITY TYPE:
740
ADDRESS:1662 W. JEFFERSON BLVD.TELEPHONE:
(213) 880-5505
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 6CENSUS: 4DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:JOSEFINA GUIAO TIME COMPLETED:
02:15 PM
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On 10/07/21 Licensing Program Analyst (LPA) Jade Jordan initiated an unannounced visit, to conduct an annual inspection, with emphasis on infection control. LPA Jordan contacted
Administrator Josefina Guiao, and the purpose of the visit was explained. LPA was met by Facility DSP staff Czarina Dorotan.

Upon Entry LPA observed Required Positing in regards to Covid 19, on the exterior of the facility, as well as the interior. The facility has followed their mitigation plan, and the facility was prepared with Sanitizer, Surgical Masks, gloves, visitor/staff/ resident symptom screening logs and Thermometer. A minimum of 30 Day supply of Full PPE was Available.

The Facility is a one story family home, the inside physical plant consists of four (4) bedrooms , two (2) bathrooms, living/dining, kitchen and back house unit, used as a staff office.

Bedrooms:
The facility has four (4) bedrooms for Clients. Each room include (1) full size bed, (1) chair, dressers ,lamps, and closet space for all Clients. All bedrooms are equipped with a ceiling light. All rooms had closets for ample storage.



SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON MANOR
FACILITY NUMBER: 198601899
VISIT DATE: 10/07/2021
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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hallway near the kitchen.

Appliances:
Stove burners, oven, microwave, washer, and dryer are working.


Upon initial entry LPA observed Pad Lock on outside gate, during Physical Plant Tour LPA observed a dead bolt lock on client bedroom. LPA advised this is not within compliance citations will be issued for the following area.

An exit interview was conducted and copy of this report was provided.




SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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Document Has Been Signed on 10/29/2021 03:58 PM - It Cannot Be Edited


Created By: Jade Jordan On 10/07/2021 at 01:55 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: JEFFERSON MANOR
FACILITY NUMBER: 198601899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87468.1 Personal Rights of Residents in All Facilities (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. Based on LPA Observation of Pad Lock on the outside gate, and client room deadbolt these poses/posed a potential Health, Safety, or Personal Rights risk to residents in care.
POC Due Date: 10/08/2021
Plan of Correction
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Admin took the pad lock off the door same day. Administrator will submit picture within 24hrs of Deadbolt being removed, and replaced with a door handle.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Michael Cava
LICENSING EVALUATOR NAME:Jade Jordan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021


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