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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603279
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:53:06 PM

Document Has Been Signed on 01/27/2022 03:53 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: 5DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Lanny Ttie, Cargiver TIME COMPLETED:
04:00 PM
NARRATIVE
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On 01/27/2022 at 9:51 am, Licensing Program Analyst (LPA) Troy Agard and Licensing Program Manager (LPM) Angela Kendrick conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, a risk assessment was conducted by LPM Janae Hammond via telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory residents, of which one (1) can be bedridden. Facility is approved for three (3) hospice. Currently, there are five (5) residents present during today’s visit.

LPA met with Caregiver, Lanny Ttie and both toured the inside and outside grounds of the facility. LPA and LPM were properly screened for Covid-19 symptoms and temperature was checked.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station near the facility front entrance. All staff was observed with a face covering. LPA observed required postings throughout the facility.

All rooms were inspected. All rooms are shared. Bed linen were sufficient in amount, but mattresses needed bed covers, adequate lighting was provided, storage for resident personal belongings was observed.

Furniture in the living room observed to be in good condition. There are no security bars or weapons on the premises. The client bathroom was checked, toilets and water faucets worked properly. The water temperature measured at 119 F. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Cleaning supplies were observed unlocked. Centrally stored medications were observed stored in their originally received containers and observed locked and inaccessible to residents in care. One fire extinguisher was observed towards front entrance.

Cont on 9099C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MINI MANOR HOME
FACILITY NUMBER: 198603279
VISIT DATE: 01/27/2022
NARRATIVE
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Outside grounds were toured, no bodies of water observed. Walkways around the home were not clear of hazards. Common areas were observed cluttered; front doorway was free of obstruction.

During a review of records, LPA observed the facility does not have an Administrator with a valid certification which is not in compliance with PIN 21-24CCLD.

The following deficiencies were cited:

1) Personnel Records 87412

2) Resident Records 87506

3) Administrator - Qualifications and Duties 87405

4) Admission Agreements 87507

5) Personal Rights 87468.1

6) Maintenance and Operations 87303

7) Personnel Requirements – General 87411

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapters 1 and 6, see LIC 809D

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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Document Has Been Signed on 01/27/2022 03:53 PM - It Cannot Be Edited


Created By: Troy Agard On 01/27/2022 at 01:40 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: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412
Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview. LPA /LPM were unable to review staff records due to them being unavailable. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator will provide personnel records to LPA by POC due date.
Type B
Section Cited
CCR
87506a
87506 Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staf

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview. LPA /LPM were unable to review resident records due to them being unavailable. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator will provide resident records to LPA by POC due date.
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:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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Document Has Been Signed on 01/27/2022 03:53 PM - It Cannot Be Edited


Created By: Troy Agard On 01/27/2022 at 02:06 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: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405a
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in due to Administaor not having a valid certifcation on file. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Based on record review the licensee did not comply with the section cited above due to the facility not having a valid Administration certification on file. Which poses/posed a potential health, safety or personal rights risk to persons in care.

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:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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Document Has Been Signed on 01/27/2022 03:53 PM - It Cannot Be Edited


Created By: Troy Agard On 01/27/2022 at 02:14 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: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA/LPM observed admission agreements not signed by R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator will provide residents with an updated admission agreement reviewed and sign by residents and/or their responsible party. A copy of the updated agreement(s) will be sent to licensing by POC due date.
Type B
Section Cited
CCR
87468.1(a)(16)
(16) To receive or reject medical care or other services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Based on discharge paperwork for R1 their medical needs are not being met, nor does resident have access to their wheelchair. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator will obtain healthcare services for resident per his discharge paperwork. The start of health-related services must be submitted to licensing by POC due date.
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:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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Document Has Been Signed on 01/27/2022 03:53 PM - It Cannot Be Edited


Created By: Troy Agard On 01/27/2022 at 02:39 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: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed doors, a ladder, ply- wood, bed frame and dog feces in the back yard of the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator will have debris removed by POC due date and provide proof to licensing.
Type B
Section Cited
CCR
87309(a)
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed toxins and sharp knives unlocked, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator will provide staff with training on the health and safety risk of having the toxins / sharps unlocked. Proof of training must be submitted to licensing by POC due date.
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:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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Document Has Been Signed on 01/27/2022 03:53 PM - It Cannot Be Edited


Created By: Troy Agard On 01/27/2022 at 03:03 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: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(3)
d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance
(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed the caregivers were unable to effectively communicate with residents. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee / Administrator shall ensure all staff are able to communicate with residents and visitors to meet resident’s need and able to communicate and understand at all time. Licensee will submit written statement as to how staff will understand and communicate in order to meet the residents in needs by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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