565800416-10-10-2023-29-AS-MARO-CWGS99-20231010134023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800416
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:40:32 PM

Document Has Been Signed on 10/10/2023 01:40 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DARRAH MANOR		FACILITY NUMBER:	565800416
ADMINISTRATOR:	BERNADITA SALVADOR		FACILITY TYPE:	740
ADDRESS:	1579 DARRAH AVENUE		TELEPHONE:	(805) 526-7463
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 3	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Bernadita Salvador		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:00 a.m. The last annual conducted at this facility was on 09/15/2022. When the LPA arrived, there were two (2) staff and three (3) residents present. The LPA was greeted at the door by Administrator, Bernadita Salvador and the reason for the visit was explained. Entrance interview conducted.

At 8:10 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 8:20 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The knives and sharps stored locked inside the pantry. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. At 8:22 a.m., the LPA observed non-perishable canned foods that were expired – fruit cocktail (qty – 3 expired 09/2022), peanut butter (qty-2 – expired 03/2021), canned vegetables (qty – 5 expired 05/2023), Campbells soup (qty – 3 expired 10/2022), bag of raisins (qty – 3 expired 10/2018), and packaged chicken breast (qty – 3 expired 10/2022). These items were discharged upon observation.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DARRAH MANOR	FACILITY NUMBER: 565800416
	VISIT DATE: 10/10/2023

NARRATIVE

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(Report Continued from LIC 809...)

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 8:45 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed fully charged and last serviced on 3/15/2023. The LPA observed required postings throughout the common space. There is a washer and dryer by the hallway that is kept locked at all times when not in use. Cleaning supplies and detergents were observed locked and inaccessible time of the visit. The facility has at least a 30-day supply of Personal Protection Equipment (PPE). The facility has a working telephone on premises. The LPA observed working auditory alarms throughout the facility.

BACKYARD: The facility has an adequate supply of emergency food and water. The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There is one gate that self-latches. No bodies of water noted at the time of the visit.

BEDROOMS: There are three (3) resident bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 8:15 a.m., the LPA observed a bottle St. Ives lotion on top of the dresser inside bedroom #1. Item was locked immediately. There is a staff room on premises. The LPA observed a closet in the hallway with extra towels and linens.

RESTROOMS: There is one (1) resident restroom. Restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured at 111.7 degrees Fahrenheit at 8:16 a.m.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DARRAH MANOR	FACILITY NUMBER: 565800416
	VISIT DATE: 10/10/2023

NARRATIVE

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(Report Continued from LIC 809C...)

RECORDS: Records review began at 8:51 a.m.; three (3) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms.

At 8:57 a.m., record review of Resident #1’s (R1’s) and Resident #2’s (R2’s) file review revealed that on R1’s Physician’s Report dated 06/12/2023 and R2’s Physician’s Report dated 05/26/2023 it states both R1 and R2 are at risk if allowed access to personal grooming and hygiene items.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

The current Administrator’s file was also reviewed, and it was in order.

The last emergency disaster drill was conducted on 09/30/2023.

At 10:25 a.m., the LPA interviewed two (2) staff members.

During today’s visit, the LPA obtained copies of the following: staff roster, resident roster, Emergency Disaster Plan, and a copy of the current liability insurance.

MEDICATIONS: Medications review began at 10:45 a.m.; medications are centrally stored and locked in a cabinet by the main hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 01:40 PM - It Cannot Be Edited

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DARRAH MANOR	FACILITY NUMBER: 565800416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(g)

Care of Persons with Dementia

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review, the licensee did not comply with the section cited above as personal hygiene items were accessible to resident in care at the time of the visit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Items were locked immediately. Plan of Correction has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/10/2023 01:40 PM - It Cannot Be Edited

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DARRAH MANOR	FACILITY NUMBER: 565800416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as expired canned food was observed in the facility pantry, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Food observed to be expired was discarded. Plan of Correction has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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