191221245-9-17-2021-31-AS-LQLY-C6XTDV-20210917143857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221245
Report Date: 09/17/2021
Date Signed: 09/17/2021 02:40:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CARROLL MANOR		FACILITY NUMBER:	191221245
ADMINISTRATOR:	MILLER, VIRGINIA		FACILITY TYPE:	740
ADDRESS:	38161 N. 90TH STREET		TELEPHONE:	(661) 944-1085
CITY:	LITTLEROCK	STATE: CA	ZIP CODE:	93543
CAPACITY:	31	CENSUS: 10	DATE:	09/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Monina Miller		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 10:12am to conduct a One (1) year Required Infection Control visit. LPA meet with the Administrator Monina Miller & Virginia Miller and explained the purpose of this visit. A tour of the physical plant was conducted at 10:18am and the following was observed: The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) posted. The PPE screening station is located at the entrance of the facility and is equipped with sufficient PPE readily accessible with hand sanitizer, gloves, mask and sign in sheet at the time of visit. The facility has sixteen (16) bedrooms which are designated for residents. Eleven (11) located in the front main house which is being occupied by three (3) out of ten (10) residents in care. The second house is located behind the main house and is occupied by seven (7) out of 10 residents in care. The third house is adjacent to the main house and is occupied by the licensee Virginia Miller and Monina Miller. The fourth house is located to the front left of the main house and is occupied by staff Eric Miller. The facility maintains a comfortable temperature of 75 degrees. Administrator Monina Miller, Virginia Miller and Eric Miller are the only live in staff during this visit. The facility has an approved mitigation plan on file. Kitchen: At 10:27am LPA observed the kitchen to be clean and an adequate supply of perishables and non-perishable food located in the fridge, freezer, pantry, and deep freezer located in a room adjacent to the kitchen where the emergency food is also stored. Food is properly labeled and stored. Food storage and preparation areas are clean and inaccessible to pests. Trash cans observed to be with tight fitting lids. Continue LIC 809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARROLL MANOR	FACILITY NUMBER: 191221245
	VISIT DATE: 09/17/2021

NARRATIVE

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Sharps were observed to be stored inaccessible to residents in a locked kitchen drawer. Toxins, poisons, and cleaning supplies were observed to be locked and stored in the cabinet underneath the sink. LPA observed four (4) Fire Extinguishers in the main house two (2) located in the kitchen one (1) in the hallway and 1 near the front door entrance and 1 in the back house all have a service tag of 11/4/20.

Medication: At 10:38am the medication cabinet was observed to be locked and located in the office inaccessible to residents. First aid kit and manual observed to be stored in the office near the medication cabinet.
Storage Rooms: At approximately 10:56am LPA observed six (6) storage areas in the main house, storage one (1) located near the living room. Storage 2 located near bedroom 4 by the exit sign all including rooms 5 and 7 are sufficiently stocked with toiletries, incontinent supplies, and PPE. Room six (6) is storing old equipment, wheels chairs, bed frames and old furniture were all observed to be locked and inaccessible to residents in care. 1 located near bedroom 4 labled linen which is where the extra linen and towels are stored.

Client Rooms: At 11:11am LPA observed eight (8) out of (16) bedrooms being occupied by residents to be clean, properly furnished, and have appropriate bedding and linens. All have adequate and sufficient lighting. Bedroom number 5 is used for when any residents needs to be quarantine it is stocked with sufficient PPE (gloves, gowns, mask, hand sanitizer).

Bathrooms: LPA observed at 11:23am 1 bathroom being used in the main house for showers to be clean and in good repair with appropriate grab bars and non-skid mat. Each resident room has a half bath for private use. LPA observed two and a half bathroom in the back house to be clean and in good repair with appropriate grab bars and non-skid mat. The hot water temperature measured in range of 106.9 to 117.6. LPA observed appropriate hand washing signs posted in each bathroom, towels and washcloths are not shared.

Laundry Room: At 11:37am LPA observed the laundry room to be clean and clear from obstruction. Toxins and washing detergents were observed to be locked and stored in a cupboard inside the laundry room next to the washing machine.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARROLL MANOR	FACILITY NUMBER: 191221245
	VISIT DATE: 09/17/2021

NARRATIVE

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Living, dining room and common areas: Observed to have sufficient tables and chairs for seating and lighting. Sofa and love seats observed to be clean and in good repair. The rooms are also equipped with television for viewing preferences. Activity supplies are located and stored in the dining room against the wall free from obstruction.
Backyard: LPA observed the outside of the facility at 11:49am, which in enclosed and gated. The back yard was observed and the outside area and around the building of the facility observed to be clean and clear of debris. No bodies of water observed on the property. The facility has 3 sheds on the property, 1 behind the house and 2 adjacent to the left side of the house all were observed to be locked and storing personal belongings (Christmas ornaments, paperwork, tools and old furniture) inaccessible to residents. The front yard has a table and chair for seating as well as 2 swings under a shaded area.
At 12:02pm the fire alarm system was tested and observed to be working, it is hard wired and interconnected and carbon monoxide is detector in kitchen.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

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