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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603279
Report Date: 09/30/2021
Date Signed: 09/30/2021 07:27:18 PM

Document Has Been Signed on 09/30/2021 07:27 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
MONTEREY PARK, CA 91754
FACILITY NAME:MINI MANOR HOMEFACILITY NUMBER:
198603279
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1606 S. HOLT AVETELEPHONE:
(424) 284-3258
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 4DATE:
09/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Lan Nio-CaregiverTIME COMPLETED:
04:00 PM
NARRATIVE
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On 9/30/21, Licensing Program Analysts (LPA) Martessa Brown conducted a case management. LPA was met by Lan Nio, the Caregiver. LPA explained the purpose of todays visit.

LPA was told by administrator the police came to facility yesterday regarding resident R1 and staff #1. LPA did not receive an incident or a police report. Administrator stated was in the process the reports. Staff #1, showed LPA a written statement that was in a note book related to the incident.

During today's visit LPA observed injures to resident #1. LPA interviewed r1 regarding the incident. LPA asked administrator regarding this incident and informed her LPA did not receive an incident report.

Deficiency Cited Under California Code of Regulations Title 22, Division 6 Chapter 8 and civil penalties assessed.

See attached LIC 809-D

An exit interview conducted report and appeal rights given .

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/30/2021 07:27 PM - It Cannot Be Edited


Created By: Martessa Brown On 09/30/2021 at 03:08 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: MINI MANOR HOME
FACILITY NUMBER: 198603279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
87211(a)(D)

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87211 Reporting Requirement:
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse...

This requirement was not met as evidence by:
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Administrator will provide incident reports and submit to LPA. Administrator will review Title 22 and provide a written statement that she read and understood the regulation and will submit to LPA by POC due date 10/8/21.
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During LPA's interviews conducted with administrator and resident #1. Administrator did not submit an incident report to LPA regarding R1's incident's at the facility.
This poses a potential health and safety risk to all 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:Janae Hammond
LICENSING EVALUATOR NAME:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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