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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607950
Report Date: 12/18/2023
Date Signed: 12/18/2023 03:15:46 PM

Document Has Been Signed on 12/18/2023 03:15 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNLAND MANOR INC.FACILITY NUMBER:
197607950
ADMINISTRATOR:ARYEH ROSNERFACILITY TYPE:
735
ADDRESS:10540 SHERMAN GROVE AVETELEPHONE:
(818) 352-5941
CITY:SUNLANDSTATE: CAZIP CODE:
91040
CAPACITY: 98CENSUS: 98DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aryeh RosnerTIME COMPLETED:
03:15 PM
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At 09:30AM Licensing Program Analyst (LPA) Christopher Alemoh conducted an Annual Required visit and inspection of the facility Sunland Manor. LPA met with Administrator Aryeh Rosner and explained the reason for the visit.

The facility has three (3) buildings, all were inspected.

Last fire Drill Conducted on 12/08/2023.

At 09:55am, with the assistance of Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and Sprinkler systems are hardwired and interconnected. Sprinkler system last serviced 07/15/2023. There are carbon monoxide detectors that function properly. There are (2) fire extinguishers at the ends of each hallway in all three buildings and staff offices, kitchen and medication room. The charge dates are 7/20/2023.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Two industrial freezers were observed stocked full of proteins and fruits for residents.

Medications: Locked and secured in two separate medication Room. LPA observed facility staff Lizette Valverde administering resident medication. LPA observed that Medications were safe, locked and inaccessible cabinet. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. In accordance were properly labeled medications locked in a black cabinet. LPA observed and tested facility signal system in Rm. 6 Building. Signal call box sound is triggered in the Medication Room and Administrator office, system is functioning properly. First aid kit is fully stocked with manual.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNLAND MANOR INC.
FACILITY NUMBER: 197607950
VISIT DATE: 12/18/2023
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(Contd. From LIC 809)

Bedrooms: LPA toured three (3) random resident rooms in each of the three bedrooms designated for residents' use. Each of the bedrooms are in use by residents were properly furnished with appropriate bedding and linens with sufficient lighting. At the time of visit all bedrooms all in use. Facility has one empty room that is being used as an isolation room for residents with infectious diseases.

Bathrooms: There are hallway bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. The hot water temperature was measured at 114 degrees Fahrenheit. Cleaning supplies are being stored in the outside closet on the north side of Building 1. Facility has a cleaning service that comes five days a week 8AM-5PM.

Common Areas: These included the living room and dining area. The common areas were properly furnished.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoors use. The outdoor area was free of hazards. The laundry area and detergents are secured are locked in a closet. Smoking area is located along the rear side of the facility.

At 12:05 LPA conducted a file review

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were reviewed for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D) or no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued to Administrator Aryeh Rosner.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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