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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800416
Report Date: 09/15/2022
Date Signed: 09/30/2022 04:10:54 PM

Document Has Been Signed on 09/30/2022 04:10 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 MANORFACILITY NUMBER:
565800416
ADMINISTRATOR:BERNADITA SALVADORFACILITY TYPE:
740
ADDRESS:1579 DARRAH AVENUETELEPHONE:
(805) 526-7463
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 2DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Evelyn Brosas, Assistant AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. This annual visit had a specific emphasis on infection control practices and procedures. The LPA met with staff and assistant Administrator. Reason for visit was explained.
At approximately 12:15pm today, LPA and Ms. Brosas toured the physical plant areas inside and outside to ensure the facility is in compliance with Title 22 Regulations: KITCHEN: Knives are stored inaccessible to the clients. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: resident restrooms observed clean/sanitary and in operating condition. Restroom observed stocked with liquid soap and paper towels; appropriate hand-washing signs observed posted. COMMON SPACES: In the common areas, and living room adequate furniture observed. The appropriate licensing documents and infection control postings observed posted throughout the facility. The backyard observed hazardous free. INFECTION CONTROL: During today’s visit, the LPA spoke with Ms. Brosas regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed facility supply of Personal Protection Equipment (PPE) to be adequate; Ms. Brosas stated she is able to obtain additional supplies as needed. Facility cleaning protocol is in place. Facility observed clean during todays visit. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time.
The following recommendations were made:
- N95 fit testing for all staff
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
-Staff and residents should be encouraged to wear masks while in common areas.
Exit interview conducted. Copy of todays report provided via email to the Licensee/Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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