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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221245
Report Date: 10/12/2024
Date Signed: 10/12/2024 12:32:45 PM


Document Has Been Signed on 10/12/2024 12:32 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:CARROLL MANORFACILITY NUMBER:
191221245
ADMINISTRATOR:MILLER, VIRGINIAFACILITY TYPE:
740
ADDRESS:38161 N. 90TH STREETTELEPHONE:
(661) 944-1085
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:6CENSUS: DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Monina Miller - AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Gary Tan, met with Administrator Monina Miller for a One (1) year required visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 9:31 AM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors.. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front yard. The facility has sufficient stock of PPE in the storage room.

The facility has five (5) bedrooms and three (3) bathrooms currently occupying five (6) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is licensed to care for six (6) non-ambulatory resident and hospice waiver for four (4) residents.
Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted:
Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 76°F. The smoke detectors were last tested on 09/24/24. There is a fire extinguisher located in the bedroom hallway and was observed to be full and last serviced on 04//22/24. The facility is equipped with sprinkler and fire pull system and last inspected on 09/24/24.
The backyard of the facility was wide open and the building itself is part of a two (2) acre lot with multiple buildings. There is an outdoor furniture on the lot before the gate of this house, with a covered shaded area for clients. There is no body of water in the facility. There are two (2) tool shed being used as storage for decors and equipment. The sheds are observed to be locked during visit. (continued on LIC 9099-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARROLL MANOR
FACILITY NUMBER: 191221245
VISIT DATE: 10/12/2024
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(continued from LIC 809)

There is no garage at this building. There is a big parking lot upon entrance of the main gate.

Food Service/Kitchen is located in the former main building adjacent to current building. It is sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The kitchen is inaccessible to residents. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: There is no staff room at this building.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 111.8°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication storage is located also in the former main building. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet.

Client records: Client records are reviewed. all residents' file appeared to be complete and updated.

Staff records: LPA conducted a complete file review of staff records. Staff files appeared to be complete and updated.

Disaster drill was last conducted on 09/12/24 . Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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