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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602381
Report Date: 01/16/2026
Date Signed: 01/16/2026 04:56:20 PM

Document Has Been Signed on 01/16/2026 04:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MAGNIFICENT MANORFACILITY NUMBER:
198602381
ADMINISTRATOR/
DIRECTOR:		MINDA MCNAMARAFACILITY TYPE:
740
ADDRESS:22831 MADRONA AVENUETELEPHONE:
(310) 326-1617
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 6DATE:
01/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:57 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 01/16/26, Licensing Program Analyst, Wendy Gibbs, conducted an unannounced 1-year Required Annual Visit to the facility listed above using the full CAREs tool. LPA met with Nadine ‘Susana’ Sibayan, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The facility is licensed to serve six (6) non-ambulatory clients, age sixty (60) and over, four (4) of which may be bedridden, with an approved hospice waiver of four (4). There are currently six (6) residents residing in the facility.
Files The LPA reviewed six (6) resident files and found they contained the required documents. The LPA reviewed the Administrator and three (3) staff files and found they contained the required documents, training, and certification. LPA observed the administrator’s Administrator Certificate #7015514740 is valid till 04/02/2026, During record review, LPA observed licensing fees are current.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet in hall and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for six (6) residents. LPA observed six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records.
Safety The LPA observed smoke detectors and carbon monoxide were operable. The LPA observed a fully charged fire extinguisher last serviced on 07/08/25. The last Fire Prevention Inspection was last conducted on 07/11/25, by the Torrance Fire Department. The last emergency drill was conducted on 09/25/25. LPA observed all exits clearly marked. LPA observed the Emergency Disaster Plan (LIC610E) posted and last updated on 02/21/2025. The facility has a working landline telephone. LPA reviewed and received a copy of liability insurance through Allied Health that is valid till 03/06/26. LPA inspected the First Aid Kit and found it contained the required items and a current manual. The LPA observed all mandated signs and documents posted throughout the facility.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2026
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381
VISIT DATE: 01/16/2026
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Infection Control During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station, and visitors log upon entry. LPA observed it has hand sanitizer, masks, gloves, sanitizing wipes, and a thermometer available. All mandated infection control signs were posted throughout the facility.

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.

LPA was unable to complete the annual inspection during today’s visit and will return to complete the inspection on a later date.

An exit interview was conducted with Assistant Administrator Nadine ‘Susana’ Sibayan, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC809 (FAS) - (06/04)
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