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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603279
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:37:25 PM

Document Has Been Signed on 01/06/2023 03:37 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:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Eilat NahumTIME COMPLETED:
03:30 PM
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On 01/06/2023 at 1:30 pm, Licensing Program Analyst (LPA) Antonia Alvizar 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 LPA Alvizar via telephone with Staff, Eilat Nahum and the purpose of today’s visit was explained. Based on the assessment, the facility is clear of Covid-19 infection.

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, Lannie Nio and later Administrator, Eilat Nahum met us and toured the inside and outside grounds of the facility. LPA was 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 and residents were 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 119.1 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. 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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: MINI MANOR HOME
FACILITY NUMBER: 198603279
VISIT DATE: 01/06/2023
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Outside grounds were toured, no bodies of water observed. Walkways around the home were clear of hazards. Common areas were observed with no cluttered; front doorway was free of obstruction.

LPA observed the facility have an Administrator Certificate with valid date posted on the wall. Administrator, Eilat provided LPA a copy of Certificate of Liability Insurance.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.



No deficiencies cited under California Code of Regulations Title 22,

Exit interview conducted and a copy of the report was provided to Administrator, Eilat Nahum.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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