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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201352
Report Date: 11/12/2024
Date Signed: 11/12/2024 12:33:02 PM

Document Has Been Signed on 11/12/2024 12:33 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COZY FAMILY CAREFACILITY NUMBER:
079201352
ADMINISTRATOR/
DIRECTOR:		PANTONIAL, MARILYNFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(650) 201-1634
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:MARILYN PANTONIAL, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
11:12 AM
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On 11/12/2024 at 9:40am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced pre-licensing inspection LPA met with Marilyn Pantonial, Administrator. The facility has a fire clearance for six (6) non-ambulatory residents.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, backyard. The facility has a total of seven (7) bedrooms which one (1) is occupied by staff, the facility has two (2) bathrooms. No bodies of water observed. There is sufficient lighting around the facility. Client’s rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms shower/tub was equipped with a nonskid mat. Passageways and hallways are free of obstruction. Locked closet available to store medications. Hot water temperature is measured at 116.7 Fahrenheit in shared clients' bathroom. Fire extinguisher was serviced on 12/15/2024. First Aid kit was complete. Carbon monoxide and smoke detectors present and in working condition.

Facility needs to correct the following issues:

· Lighter, scissors in an unlocked drawer, and scissors in the dishwasher.

continue on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COZY FAMILY CARE
FACILITY NUMBER: 079201352
VISIT DATE: 11/12/2024
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continued from LIC809

· Facility dose not have enough food. Purchase food non-perishable and perishable.



· Staff living in the garage storage room.

· missing screen on the kitchen window.

· unlocked medication in garage storage/bedroom.
  • unlocked Round-up weed killer in the backyard.
  • fruit picker in the back yard.

Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted with Administrator and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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