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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602864
Report Date: 11/23/2021
Date Signed: 11/24/2021 12:41:24 PM

Document Has Been Signed on 11/24/2021 12:41 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:SENIOR MANOR CAREFACILITY NUMBER:
198602864
ADMINISTRATOR:STEVEN GRADNEYFACILITY TYPE:
740
ADDRESS:2011 SANTA RENA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 5DATE:
11/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Steven GradneyTIME COMPLETED:
03:45 PM
NARRATIVE
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On 11/23/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit. LPA was greeted by Staff Gloria Somintac and soon later Licensee/Administrator Steven Gradney joined the visit. LPA observed deficiencies while conducting a 10-day complaint visit on 11/23/2021.

LPA observed and took photos of of the following areas in the facility that need repair:
1. Kitchen cabinet - LPA Montoya did not observe a cover of a bottom kitchen drawer.
2. Clogged sink - LPA observed the sink in the common bathroom is clogged
3. Broken ramp - LPA observed the ramp covered with turf in the backyard is broken. LPA looked under the turf and discovered the wooden ramp is broken.

California Code of Regulations, Title 22, Division (6) and Chapter (1) is being cited on the attached LIC 809D.

Exit Interview was conducted and appeal rights were explained. LPA was unable to furnish a copy of the report due to a technical issue. A a copy of this report was emailed to Administrator Steven Gradney.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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 11/24/2021 12:41 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 11/23/2021 at 02:41 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
MONTERY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE
FACILITY NUMBER: 198602864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2021
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee/Administrator shall repair the drawer, sink and the ramp by the POC due and email proof of corrections to Lourdes.Montoya@dss.ca.gov
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On 11/23/2021, LPA observed a cover for a kitchen drawer is missing, bathroom sink is clogged, and a ramp in the backyard is broken. This poses a potential Health, Safety and/or Personal rights risk to residents 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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021


LIC809 (FAS) - (06/04)
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