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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601899
Report Date: 10/22/2025
Date Signed: 10/22/2025 04:02:21 PM

Document Has Been Signed on 10/22/2025 04:02 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:JEFFERSON MANORFACILITY NUMBER:
198601899
ADMINISTRATOR/
DIRECTOR:		CZARINA DOROTANFACILITY TYPE:
740
ADDRESS:1662 W. JEFFERSON BLVD.TELEPHONE:
(213) 880-5505
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 6CENSUS: 3DATE:
10/22/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:IRENE LEONOR - CARE GIVERTIME VISIT/
INSPECTION COMPLETED:
02:02 PM
NARRATIVE
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On 10/22/2025, Licensing Program Analyst (LPA) Troy Watson arrived at the facility listed above to conduct an unannounced Case Management-Other visit to follow up on a facility fire incident. LPA met with the Care Giver Irene Leonor and explained the purpose of the visit.

LPA Watson conducted a case management visit to gather information on a fire that occurred on the premises of the above listed facility on 10/17/25 at approximately 7:00PM. According to information reported on an Unusual Incident Report the fire only caused damage to an unattached storage unit located in the back of the facility.

The Case Management visit consisted of:

On 10/22/25, LPA requested, obtained and reviewed the following: Staff Schedule, Resident Roster, Unusual Incident Report and the Los Angeles Fire Department Public Fire Report, (LAFD) Public Fire Report. On 10/22/25, LPA conducted interviews with Staff#1 – Staff#2 (S1-S2).

CONTINUED ON LIC9099-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Troy Watson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: JEFFERSON MANOR
FACILITY NUMBER: 198601899
VISIT DATE: 10/22/2025
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On 10/22/25, LPA Watson interviewed Staff#1 – Staff#2 (S1-S2) about the fire incident that occurred at the facility listed above. Out of those interviewed both confirmed that no injuries to residents because of the fire. The administrator stated that a staff member called 911 at approximately 7:00PM. The responding fire department was Station #26 who responded to a call at approximately 6:50 PM on 10/17/25. The administrator explained that the residents responded to the smoke alarms that sounded off in the main building and evacuated to the front of the residence according to their fire drill training. After evacuation was completed, all residents inspected were without any injuries. According to staff interviews the fire to the storage unit was extinguished by the Fire Department within minutes. LPA Watson took photos of the fire and smoke damage to the storage unit and the debris that resulted from the fire incident. According to the Licensee The Los Angeles Fire Department Captain Balestra has stated that the cause of the fire is unknown.

An exit interview was conducted with the Licensee and a copy of this report was given to the facility.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Troy Watson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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