565850331-9-19-2023-29-AS-MARO-CVTVWS-20230919164825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850331
Report Date: 09/19/2023
Date Signed: 09/19/2023 04:48:32 PM

Document Has Been Signed on 09/19/2023 04:48 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:	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: 3	DATE:	09/19/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Rajwinder Chadha		TIME COMPLETED:	05:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a Post Licensing at 2:05 p.m. When the LPA arrived, there was two (2) staff and three (3) residents present. The LPA was greeted by staff Geraldine Ybanez and Richard Ibanez and informed them of the reason for the visit. Administrator Rajwinder Chadha was notified of the LPA’s visit via telephone and arrived at the facility at 3:30 p.m. Entrance interview conducted.

The LPA, along with staff, 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: Kitchen knives are stored in a locked drawer. Cleaning supplies were observed under the kitchen sink locked and inaccessible. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food.

BEDROOMS: There are four (4) single occupancy bedrooms and one (1) double occupancy bedrooms in the facility for resident use. The facility has a separate staff unit. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. All direct exits were clear, and no obstructions were noted.

RESTROOMS: The resident restrooms were clean and sanitary with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured in both resident bathrooms and they measured between 105 and 120 degrees Fahrenheit at the time of the visit.

(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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: 09/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Report Continued from LIC 809...)

COMMON AREAS: Living room and dining room furniture was observed to be in good condition, and the lighting was adequate. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The fire extinguisher was observed to be new and fully charged. The LPA observed required postings throughout the common space and upon entry into the facility. There is a functioning telephone on the premises. All exit doors were observed with functioning auditory alarms. There is a fireplace with an adequate safety screen at the time of the visit.

Facility has one central entry point designated for universal screening. Alcohol-based hand sanitizer and masks available upon entry. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE).

MEDICATIONS / FACILITY FILES: Medications are in a cabinet adjacent to the living room which is locked and inaccessible to residents in care. Files were also observed in a cabinet adjacent to the living room. The first aid supplies were complete.

LAUNDRY: The laundry area is located in the garage which is locked and inaccessible to residents in care.

GROUNDS: The exterior passageways were clean and clear of any obstructions. The LPA observed one (1) self-latching gate for emergency use. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water on the premises at the time of the visit.

During today’s visit, interviews conducted revealed that Staff #1 (S1) has been working in the facility since June 2023 and Staff #2 (S2) has been working in the facility since July 2023. The LPA reviewed the facility Guardian roster and discovered that both S1 and S2 have fingerprint background clearance but are not associated to this facility.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $1,000. Failure to correct the deficiency may result in additional 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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/19/2023 04:48 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: MANRA MANSION LLC	FACILITY NUMBER: 565850331
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, as S1 and S2 have not been associated to the facility, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Administrator agreed to do the following: 1. Will submit the LIC 9182 transfer request form to ensure both S1 and S2 are associated to the facility. 2. Plan of Correction has been met at the time of the visit. Penalties have been assessed to day in the amount of $1,000

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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3