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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601899
Report Date: 11/07/2025
Date Signed: 11/07/2025 12:51:37 PM

Document Has Been Signed on 11/07/2025 12:51 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: 4DATE:
11/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Czarina Serrano-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:51 PM
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On 11/07/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Czarina Serrano the Administrator. LPA explained the purpose of today’s visit. The facility is a one-story Residential Care Facility for the Elderly (RCFE) home, licensed to serve dementia adults aged 60 and above of which (1) can be non-ambulatory and (3) ambulatory. The facility has no approved hospice waiver, and currently the facility has (4) residents.

The facility features approximately (4) bedrooms and (2) bathrooms. The facility has a kitchen, a dining area, living room, an outside patio area, an attached storage area, an unattached laundry room containing a refrigerator with extra food supplies located at the back of the facility.

LPA Watson and the Administrator Serrano toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (4) bedrooms and (2) bathrooms.

All residents’ rooms were inspected. Mattresses linen and box springs were inspected and observed to have mattress covers, clean and free from infestation. Bed linens, comforters and bath towels were adequately stocked at the time of visit. The first aid kit was checked and fully stocked with tweezers, tape, gauze, Band-Aid's, thermometer and certified manual.

The evaluation Report continues the next page, LIC 809-C, providing further details of the inspection findings.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Troy Watson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2025
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: 11/07/2025
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The bathrooms were inspected, toilets and water faucets worked properly, and showers were free of mold and mildew. Each resident’s room contained a chair, lamp, drawer, dresser, and plenty of closet space. There is adequate lighting in the hallway, including a night light and sufficient toiletries are available for the residents.

The beds and bedding supplies were in good condition, adequate lighting was provided in each room, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. The facilities (8) Smoke / Carbon monoxide detectors were in operable condition. The water temperature ranged from 107.5 °F in the kitchen and between (118.7 °F in bathroom #1 and 118.8 °F and in bathroom#2) the room temperatures ranged from 72.6 °F to 73.1°F.

During the visit, LPA Watson observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were locked up in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All (3) fire extinguishers were charged and operable. The last Fire / Disaster Drill, according to facility records, were conducted on 04/25/25. The department conducted a review of (4) residents' service files and (1) staff personnel file. LPA reviewed (4) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of the facilities liability insurance was current and showed an expiration date of 03/26/2026. Facility Annual Fees were current.

An exit interview was conducted with the Administrator Czarina Serrano, and a copy of the Facility Evaluation Report was provided to the facility.

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

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC809 (FAS) - (06/04)
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