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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602226
Report Date: 08/14/2022
Date Signed: 11/16/2022 09:52:38 AM

Document Has Been Signed on 11/16/2022 09:52 AM - 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:PVE MANORFACILITY NUMBER:
198602226
ADMINISTRATOR:RHODA MABUTASFACILITY TYPE:
740
ADDRESS:3916 PALOS VERDES DRIVE NORTHTELEPHONE:
(310) 375-8996
CITY:PALOS VERDES ESTATESSTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 5DATE:
08/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:JM Demafelix, Area SupervisorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Andrea Narvaez, Care giver and later met with Jm Demafelix and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (3) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (7) bedrooms, (3) full bathrooms, , shaded back yard, front yard, laundry room and a detached 2 garage.

LPA and Andrea toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-5 are occupied by residents and contain the mandated furniture. Bedroom #6 is vacant & Bedroom 7 is a staff bedroom. The (2) bathrooms are clean and operational. 3rd bathroom is a staff bathroom. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is (108.6) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguisher is fully charged. Exit, walkways and/or passageways, and front yard is clear and free of debris. Back yard is blocked due to construction. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2022
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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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: PVE MANOR
FACILITY NUMBER: 198602226
VISIT DATE: 08/14/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in all the bathrooms and additional sanitation supplies are stored in the 2nd bathroom. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan is not posted, Fit testing not completed for staff. Required postings throughout the facility. The resident’s temperatures are checked and logged (2x a day). PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisory (TA) issued. Fit testing for staff not completed and Mitigation Plan not posted.

An exit interview conducted with Jm Demafelix and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022
LIC809 (FAS) - (06/04)
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