565800416-9-30-2024-29-AS-MARO-D9LTQ9-20240930145534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800416
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:55:38 PM

Document Has Been Signed on 09/30/2024 02:55 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:	09/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Bernadita Salvador		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were three (3) staff and two (2) residents present. LPA was greeted by the Administrator, Bernadita Salvador and at this time the reason for the visit was explained. Entrance interview conducted.

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 11:20am. Knives and sharps were observed locked and inaccessible at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: This includes the living room and dining room area. The common areas were furnished appropriately and appeared to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Cleaning supplies, detergents, and toxins were observed in a locked cabinet inaccessible to residents in care. Activities for resident use were observed. There is a working telephone on premises. LPA observed auditory alarms at the time of the visit. Fire extinguisher was observed fully charged with a date of 03/15/2024. At 11:23am, the smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 08/27/2024.

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: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DARRAH MANOR	FACILITY NUMBER: 565800416
	VISIT DATE: 09/30/2024

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Report Continued from LIC 809...

RESTROOMS: There is one (1) resident restroom which was observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured at 105.2 degrees Fahrenheit at 11:16am.

BEDROOMS: There are three (3) bedrooms for resident use; all of which are designated for double occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed in the hallway closet. Staff bedroom observed on premises

BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 11:30am and Personnel Records at 12:09pm.

Three (3) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete.

Three (3) personnel files 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 complete.

MEDICATIONS: Medications review began at approximately 12:55pm. 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. Medication appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. Report was reviewed and a copy issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC809 (FAS) - (06/04)

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