191221245-10-26-2022-31-AS-MRUZ-CKL2BV-20221026171545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221245
Report Date: 10/26/2022
Date Signed: 10/26/2022 05:16:31 PM

Document Has Been Signed on 10/26/2022 05:16 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, 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: 9	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Virginia & Monina Miller		TIME COMPLETED:	02:30 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) Melissa Ruiz arrived at the facility at 1:00 p.m. 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. An entrance interview was conducted. A tour of the physical plant was conducted, 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 facility and the second dwelling area is located behind the main house and has five (5) resident rooms. 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. The facility maintains a comfortable temperature of 69 degrees. Kitchen: 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. Trash cans observed to be with tight fitting lids. 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 fire extinguishers to have a service date of 3/13/2022. (cont. LIC9099-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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

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: 10/26/2022

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
26
27
28
29
30
31
32

Medication: The medication cabinet was observed to be locked and located in the office inaccessible to residents. First aid kit and observed to be stored in the office near the medication cabinet. Resident Rooms: LPA observed resident bedrooms currently occupied by residents to be clean, properly furnished, and have appropriate bedding and linens. All have adequate and sufficient lighting. Bathrooms: LPA observed bathrooms 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 appropriate hand washing signs posted in each bathroom, towels and washcloths are not shared. Laundry Room: 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. 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, 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 and are inaccessible to residents. The front yard has a table and chair for seating under a shaded area.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2