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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850190
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:51:12 PM

Document Has Been Signed on 01/24/2025 03:51 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 #1FACILITY NUMBER:
195850190
ADMINISTRATOR/
DIRECTOR:		QUINTERO, ELEANORFACILITY TYPE:
740
ADDRESS:5881 HILLVIEW PARK AVETELEPHONE:
(818) 855-7030
CITY:VALLEY GLENSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 4DATE:
01/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:58 PM
MET WITH: ANNA B DELROSARIO LEE- Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 1/2/2025. At 12:58 p.m. LPA Mosley was greeted by staff and Administrator, Anna Bernice D. Lee and the reason for the visit was explained. Entrance interview.

On 1/2/2025, it was reported that Resident 1 (R1) walked out the facility at night around 11pm and fell into a rose bush outside the facility. At this time the alarm was activated, and staff responded and assisted the resident. The staff notified the Administrator and called 911. When the paramedics arrived, they examined the resident and advised facility staff, Staff 1 (S1) and Staff 2 (S2) of the residents elevated heart rate and suggested the resident be taken to the emergency room for further observation.

During today's visit, from 1:00 p.m. LPA conducted a physical plant tour to ensure there were no immediate health and safety concerns. LPA tested all exit door alarms, and they were functioning during today’s inspection .Starting at 1:20 p.m, conducted in-person interviews three (3) staff including the Administrator. LPA also conducted a file review along with obtained copies of pertinent documents relevant to the incident.

Interviews with the staff revealed that the resident does not have any history of elopement or wandering. Staff state that this incident was unlike the resident’s typical behavior and believe it could be due to the change in medication. Staff state that the day of the incident at around 11pm the alarm was activated because the resident went out the front door and fell into a rose bush and appeared confused. The staff called the paramedics, and the resident was transferred to the hospital for further observation and evaluation.

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)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #1
FACILITY NUMBER: 195850190
VISIT DATE: 01/24/2025
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Report Continued from LIC 809...

Interview with the Administrator revealed that the incident that occurred is unusual behavior for the resident and have not experienced this type of behavior from R1. It was noted that the change in medication can be the possible cause of R1 being confused. The Administrator states when the resident returns to the facility the resident will be closely monitored along with live in staff frequently monitoring the resident at night upon arrival.

File review support that there have not been any other incidents pertaining to elopement or wandering for R1. File review support that the resident had recently returned from a Skilled Nursing Facility with a change in medications. The Administrator also showed the LPA still shots from video footage of the caregiver assisting the resident when they existed the facility and information obtained from the incident reveal staff responded timely to the incident.

No deficiencies were observed during today’s inspection. Exit interview conducted. Report was reviewed and a copy was 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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