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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002891
Report Date: 06/16/2025
Date Signed: 02/11/2026 11:27:09 AM

Document Has Been Signed on 02/11/2026 11:27 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FOOTHILL COTTAGEFACILITY NUMBER:
045002891
ADMINISTRATOR/
DIRECTOR:
ABEJO, KRISTINEFACILITY TYPE:
740
ADDRESS:3064 CEANOTHUS AVENUETELEPHONE:
(530) 809-0418
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 6CENSUS: DATE:
06/16/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kristine Abejo, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On June 16, 2025, an office meeting was held to discuss an incident that occurred on April 24, 2024, and the results of the subsequent Investigations Bureau (IB) investigation. In attendance were Regional Manager Alycia Rayner, Licensing Program Manager Troy Ordonez, Licensing Program Analyst Kayla Adkison, Licensee/Administrator Kristine Abejo, and Michael Goryan, Licensee's Consultant.

On April 24, 2024, at approximately 0400 hours, a resident (R1) experienced a "slide" while in the presence of staff. Based on the Unusual Incident Report (UIR) , and the Department's interviews with staff and day program personnel, the resident reported pain and was observed with swelling, but emergency medical assistance was not sought immediately.

On April 25, 2025, at approximately 0940 hours, the resident was sent to the medical clinic were x-rays were taken. As a result, at approximately 1146 hours the resident was transferred from the medical clinic, via ambulance, to the emergency room. Medical attention was delayed for nearly 29 hours, and the resident was ultimately diagnosed with fractures that required emergency surgery, physical therapy, and the resident suffered prolonged pain. This delay in care constitutes a failure to meet the requirements under Title 22, Section 87465(g), which mandates that 9-1-1 be called immediately when there is an imminent threat to a resident’s health.

As a result of the resident’s injury and the facility’s failure to seek medical attention in a timely manner, the violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49.

CONTINUED ON LIC-809C.

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/11/2026 11:27 AM - It Cannot Be Edited


Created By: Kayla Adkison On 06/16/2025 at 11:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL COTTAGE

FACILITY NUMBER: 045002891

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2025
Section Cited
CCR
87465(g)

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Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis …
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Licensee shall update and submit the facilities emergency response policy and training plan for all direct-care staff. Updated Policy shall be submitted by end of business on 06/17/24.
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This requirement has not been met as evidenced per the department's investigation which substantiated that R1 did not receive timely medical care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891
VISIT DATE: 06/16/2025
NARRATIVE
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The licensee was encouraged to:


-Review regulations on Restricted Healthcare Plans

-Review regulations on Prohibited Healthcare Plans

-Review when to call 9-1-1

-Update the facility’s policies and procedures for seeking timely medical attention.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
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