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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850185
Report Date: 01/24/2025
Date Signed: 01/24/2025 12:29:11 PM

Document Has Been Signed on 01/24/2025 12:29 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 #4FACILITY NUMBER:
195850185
ADMINISTRATOR/
DIRECTOR:		QUINTERO, ELEANORFACILITY TYPE:
740
ADDRESS:6245 MATILIJA AVETELEPHONE:
(818) 855-7035
CITY:VALLEY GLENSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Anna Lee Delrosario - Administrator TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Anna Bernice D. Lee arrived shortly after 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 food and water. There is a laundry area, with a washer and dryer. Laundry detergent was observed in a locked cabinet. 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. Adjacent to the garage there is an attached storage room that stores extra nonperishable food and (7) seven extra refrigerators and one (1) deep freezer. Refrigerators and food pantry were checked for proper labels and expiration dates.

BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated as private resident rooms and one (1) 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. Three (3) are designated as private resident restrooms and one (1) is designated as shared/ common resident restroom. Resident restrooms were observed to be equipped with nonslip surface. Grab bars were observed in the bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured all resident restrooms and ranged between 109.2-110.6 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: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #4
FACILITY NUMBER: 195850185
VISIT DATE: 01/24/2025
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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 11:04 a.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 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 adjacent to the entrance inaccessible to residents in care.

KITCHEN: The LPA inspected the kitchen/food service area at 10:50 a.m. Knives and sharps were observed in a locked box that sits on the counter. 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 110.1 degrees Fahrenheit at 10:52 a.m.

MEDICATIONS: Medications review began at approximately 10:57 a.m. The medications are in a locked cabinet adjacent to the kitchen. Medications for four (4) residents were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.

Infection Control / Emergency disaster planning: During today’s visit the 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.

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

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

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: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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