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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850183
Report Date: 02/27/2025
Date Signed: 02/27/2025 03:06:17 PM

Document Has Been Signed on 02/27/2025 03:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COTTAGES AT THE COLONY OF VALLEY GLEN #2FACILITY NUMBER:
195850183
ADMINISTRATOR/
DIRECTOR:		QUINTERO, ELEANORFACILITY TYPE:
740
ADDRESS:5797 HILLVIEW PARK AVETELEPHONE:
(818) 855-7023
CITY:VALLEY GLENSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 6DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Anna Lee - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 12:38 p.m. Upon arrival, LPA Mosley was greeted by staff and the Administrator. LPA met with Administrator, Anna Lee and the reason for the visit was explained.

Entrance interview.

The LPA 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.



GARAGE/BACKYARD: The garage is maintained locked at all times. LPA observed an adequate amount of emergency water. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) is designated as a staff room. The staff room is kept locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are four (4) restrooms. Two (2) are designated as private resident restrooms and two (2) are designated as shared/ common resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface. Grab bars were observed in all the bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured all resident restrooms and ranged between 111.1-119.5 degrees Fahrenheit, all within the required range.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #2
FACILITY NUMBER: 195850183
VISIT DATE: 02/27/2025
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Report Continued from LIC 809...

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:54 p.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 10/08/2024. The LPA observed all required postings throughout the common space. The last emergency disaster drill took place on 12/02/2024 and are conducted quarterly with the next one scheduled in March. The facility had the second annual automatic sprinkler system checked and passed on 06/21/2024. Activities were observed in the common areas. The fireplace in the living room was adequately screened. Cleaning supplies and other chemicals are kept in a locked hallway closet inaccessible to residents in care. There is a laundry area, with a washer and dryer. Laundry detergent was observed in a locked cabinet inside the home. Emergency food and supplies were observed in a hallway closet.

KITCHEN: The LPA inspected the kitchen/food service area at 12:42 p.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 115.5 degrees Fahrenheit at 12: 43 p.m.

RECORDS: Record review began at approx. 1:03 p.m. Resident Records were reviewed beginning at 1:04 p.m. six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 1:47 p.m. six (6) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #2
FACILITY NUMBER: 195850183
VISIT DATE: 02/27/2025
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Report Continued from LIC 809...

Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate.

MEDICATIONS: Medications review began at approximately 2:29 p.m. The medications are in a locked closet adjacent to the living room at the entrance of the home. Medications for six (6) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records.

INTERVIEWS: Two (2) staff and one (1) resident interviews were conducted during the inspection. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

LPA obtained the following documents - Resident roster LIC 9020, Staff roster LIC 500, and copy of the Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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