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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602210
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:33:01 PM

Document Has Been Signed on 08/16/2023 03:33 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:INDIAN PEAK MANORFACILITY NUMBER:
198602210
ADMINISTRATOR:TORRE, RICARDO DELAFACILITY TYPE:
740
ADDRESS:27102 INDIAN PEAK ROADTELEPHONE:
(424) 206-2292
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 6DATE:
08/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Glenda Marquez-Administrator/AdministratorTIME COMPLETED:
03:13 PM
NARRATIVE
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On 08/16/23, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management Deficiencies at this facility. LPA met with Glenda Marques/Administrator and explained the purpose of the visit.

LPA was conducted an 10 day complaint visit, and during this visit LPA found unlocked cleaning solutions under the kitchen. Administrator immediately locked cleaning solutions.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conduct, appeal rights discussed and a copy of this report and appeal rights provided to Administrator.


SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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Document Has Been Signed on 08/16/2023 03:33 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 08/16/2023 at 03:20 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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Licensee will ensure all cleaning solutions are locked at all times. Licensee locked cleaning solutions while LPA was in the facility. As part of POC, licensee will re-train all staff on how to keept cleaning solutions lock at all times. Licensee will sent a copy of this training before POC due date to LPA via email.
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Based on observation, during a physical tour of the facility, LPA observed cleaning solutions not locked under the kitchen sink. This violation poses an immediate health and safety risk to clients in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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