565850331-5-12-2023-29-AS-MARO-CRRPXU-20230512114255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850331
Report Date: 05/12/2023
Date Signed: 05/12/2023 11:43:34 AM

Document Has Been Signed on 05/12/2023 11:43 AM - 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:	MANRA MANSION LLC		FACILITY NUMBER:	565850331
ADMINISTRATOR:	CHADHA, RAJWINDER		FACILITY TYPE:	740
ADDRESS:	2267 GLORYETTE AVE		TELEPHONE:	(818) 939-7452
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 0	DATE:	05/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rajwinder Chadha		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 9:00am on 05/12/2023 and met with Applicant Representative Rajwinder Chadha. The applicant has obtained fire clearance for a total capacity of five (5) non-ambulatory residents, and one (1) bedridden resident in bedroom #2 for a total capacity of six (6) residents.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 9:21am, all hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed one (1) fire extinguisher to be new and fully charged.

There are four (4) single occupancy bedrooms and one (1) double occupancy bedrooms for resident use. There is a staff bedroom for live in staff. Each bedroom is equipped with clean mattresses, pillows, and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms at 118.6 degrees Fahrenheit.

LPA toured the kitchen area at 9:16am. The facility has at least seven (7) day supply of non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in a locked drawer. Cleaning supplies were observed under the kitchen sink locked and inaccessible. The kitchen has a sufficient supply of plates, cups, cook ware and utensils.

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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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: MANRA MANSION LLC	FACILITY NUMBER: 565850331
	VISIT DATE: 05/12/2023

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Report Continued from LIC 809...

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies for future residents. There is a fireplace present with a fireplace screen for safety at the time of visit. Night-lights were present in the main hallway and common areas.

Medications and facility records will be stored and locked in a cabinet adjacent to the living room. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual.

Garage: The garage is attached to the house and will be locked at all times. The laundry room is inside the garage. Detergents, disinfectants, and cleaning supplies are stored and inaccessible. There will be no firearms/ammunition stored on the property.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use. There are two (2) sheds locked and inaccessible which will be used for storage. Physical plant is consistent with the submitted facility sketch/floor plan.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Comp III conducted with Applicant Representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was reviewed and provided to Applicant Representative Rajwinder Chadha.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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