197602537-3-30-2023-31-AS-MRUZ-CQERGH-20230330130047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602537
Report Date: 03/30/2023
Date Signed: 03/30/2023 01:01:12 PM

Document Has Been Signed on 03/30/2023 01:01 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:	MCLENNAN M. MANOR		FACILITY NUMBER:	197602537
ADMINISTRATOR:	MORENO, LALAINE P.		FACILITY TYPE:	740
ADDRESS:	8844 MCLENNAN AVE.		TELEPHONE:	(818) 892-8882
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lalaine Moreno		TIME COMPLETED:	01:10 PM

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At 9:30 a.m. Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by a staff member, and later met Administrator, who granted access to the facility and LPA explained the reason for the visit.

At 10:30 a.m., LPA conducted a tour of the facility and the following was observed:

Infection control: The facility had submitted and approved Mitigation Plan and Infection Control Plan. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff.

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen, and it was last purchased on 3/30/2023.

Medications: At 11:00 a.m., LPA observed medications are centrally stored and locked in the kitchen pantry and are inaccessible to residents in care. LPA also observed a First Aid Kit complete with the required items as per Title 22 Regulations.

Bedrooms: There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Continued LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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

FACILITY NAME: MCLENNAN M. MANOR	FACILITY NUMBER: 197602537
	VISIT DATE: 03/30/2023

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Bathrooms: LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and non-skid mat. LPA also observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: LPA toured the outside area of the facility. LPA also observed a clean covered patio and backyard furniture to accommodate the residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents.

The garage: Laundry area is in the attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility and observed to be operational.

At 10:00 a.m., LPA reviewed records of five (5) residents and four (4) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA reviewed Administrator’s Certificate and updated emergency contact information.

No citations issued during this visit. Exit interview conducted. 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: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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