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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850184
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:39:53 PM

Document Has Been Signed on 02/25/2025 12:39 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:COTTAGES AT THE COLONY OF SHERMAN OAKS #4FACILITY NUMBER:
195850184
ADMINISTRATOR/
DIRECTOR:		LEE, ANNA B DELROSARIOFACILITY TYPE:
740
ADDRESS:5430 TYRONE AVENUETELEPHONE:
(818) 855-7021
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 6DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Claudette MarasiganTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff, Claudette Marasigan and explained the reason for the visit. Entrance interview conducted.

Starting at 11:20AM, the LPA along with Staff 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. The following was observed:

Facility is a single-story residence that consists of six (6) resident bedrooms, three (3) staff rooms, and three (3) restrooms. The LPA observed one (1) fire extinguisher which was fully charged and last serviced 10/08/2024. The smoke alarms and carbon monoxide detectors were tested and functioned properly at the time of the visit. There is a fire door by the main hallway leading into the resident bedrooms. Facility has an adequate amount of emergency food and water; properly stored. The LPA observed all required postings in the hallway near the entrance area. The auditory alarms on the exit doors were tested and functioned properly at the time of visit.

KITCHEN: The LPA inspected the kitchen/food service area at 11:40AM. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 11:41AM, the hot water temperature was measured in the kitchen sink, and it measured at 106.5 degrees Fahrenheit.

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. The fireplace was adequately screened at the time of the visit. There is a working telephone on premises.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 2
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: COTTAGES AT THE COLONY OF SHERMAN OAKS #4
FACILITY NUMBER: 195850184
VISIT DATE: 02/25/2025
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Report Continued from LIC 809...
The LPA observed a complete first-aid kit and manual. Cameras observed in the common areas. No obstructions or hazards were observed inside or out.

RESTROOMS: The LPA observed all resident bathrooms. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 11:26AM, the hot water temperature was measured in resident bathrooms, and they measured within the required range at the time of the visit. Proper hand washing signs were observed posted inside bathrooms.

BEDROOMS: There are six (6) bedrooms for resident use. All bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a closet by the hallway with additional clean linens and towels for resident use.

LAUNDRY ROOM: The laundry room, which includes a washer and a dryer were observed locked and inaccessible to residents at the time of the visit. Detergents and cleaning solutions were observed in a locked closet inside the laundry room inaccessible to residents in care.



BACKYARD: The backyard has a covered patio area with patio furniture for resident use. The LPA observed a shed for storage purposes. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms and auditory alarms. Cameras were observed in the outside perimeter. No bodies of water noted at the time of the visit.

INTERVIEWS: The LPA conducted three (3) resident interviews during the inspection. No concerns were noted.

MEDICATIONS: Medications are centrally stored in a locked cabinet adjacent to the kitchen. The LPA will review medications at a later date.

FILE REVIEW: The LPA will review facility files at a later date.

Due to time constraints an LPA will return to complete the annual at a later date.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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