565850416-4-4-2024-29-AS-ZCHN-D3ZMHQ-20240404093756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850416
Report Date: 04/03/2024
Date Signed: 04/04/2024 09:46:57 AM

Document Has Been Signed on 04/04/2024 09:46 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:	MARICAR'S MANOR II		FACILITY NUMBER:	565850416
ADMINISTRATOR:	MARTNEZ, TINA MARIE		FACILITY TYPE:	740
ADDRESS:	1168 ARCANE STREET		TELEPHONE:	(805) 210-2480
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 3	DATE:	04/03/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:53 PM
MET WITH:	Maricar Lee & Tina Marie Martnez		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) Zabel Chochian arrived to this property for a pre-licensing inspection. The LPA met with applicant Maricar Lee and Administrator Tina Marie Martnez. This is a change of ownership application from Breen Residential Care - BR Care, INC (#565801904) to Maricar Manor II - Maricar's Manor, Inc (#565850416). The current census is at 3 residents. The fire clearance was granted on 12/15/2023; in which all rooms were cleared for non-ambulatory clients, in which a bedridden person is permitted in Bedroom #1. Applicant and Administrator successfully completed Component II on 02/15/2024 and Component III during todays visit. Facility is approved for four (4) hospice (terminally ill) residents. The LPA toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in the closet in the hallway. The supply of perishable, nonperishable and emergency food supply observed sufficient. The supply of dishes, cups and utensils were adequate. Appliances in the kitchen were clean and all appeared functional. BEDROOMS: There are 4 bedrooms in the facility; three (3) shared rooms designated for residents and one (1) bedroom designated for staff. Lighting in the rooms appeared adequate; set up with beds, night stands, lamps, chests of drawers, chairs and closet space. BATHROOMS: There are two bathrooms; equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature tested at 107f degrees which was within required range. COMMON AREA:* The common areas were appropriately furnished, and the lighting was adequate. The facility smoke and carbon monoxide detector system is hard wired; all were operable at the time of the visit. There is a fireplace in the living room, which is appropriately screened. The fire extinguisher was fully charged and last serviced 07/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch observed posted; all other required postings are posted in the hallway upon entry into the facility. GARAGE: The laundry area is set up in the garage. Laundry detergent and chemicals are stored inaccessible in a cabinet. An additional refrigerator is in the garage with perishable items in good condition.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 04/03/2024

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GROUNDS: The exterior passageways were clean and clear of any obstructions. 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. MEDICATIONS: Medications are in a locked cabinet in the dining/kitchen area. Complete first aid kit observed in locked cabinet in the garage. FILES: Staff and resident files are stored in a locked cabinet in the garage.

Facility is in compliance with Title 22 Regulations at this time. The CAB Analyst will notify the applicant when the license has been approved. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC809 (FAS) - (06/04)

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