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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850191
Report Date: 03/05/2025
Date Signed: 03/24/2025 10:57:36 AM

Document Has Been Signed on 03/24/2025 10:57 AM - 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 SHERMAN OAKS #1FACILITY NUMBER:
195850191
ADMINISTRATOR/
DIRECTOR:		LEE,ANNA B DELROSARIOFACILITY TYPE:
740
ADDRESS:5416 TYRONE AVENUETELEPHONE:
(818) 855-7019
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anna Lee TIME VISIT/
INSPECTION COMPLETED:
01:21 PM
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This report is being amended, due to the report being created inaccurately for Cottages #1 instead of Cottages #3. Licensing Program Analysts (LPAs) Sandra Urena and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit. At 9:50 a.m., the LPAs met with staff and explained the reason for the visit. Administrator, Anna Lee arrived at the facility shortly thereafter. The LPAs, and the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

The facility is a single-story residential home with seven (7) bedrooms, six (6) for resident use and one (1) for staff use and five (5) bathrooms.
COMMON AREAS: The LPAs observed common areas to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and last serviced on 10/09/2024. The fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices and were operational at the time of the visit. Facility telephone was observed during the time of the visit. LPAs observed cameras in the common areas, and throughout the exterior perimeter of the facility. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 73 degrees. Night lights were present in the hallways.
KITCHEN: The LPAs observed the kitchen and dining area. Knives are stored and inaccessible at the time of the visit. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food labels were observed for expiration dates. Hot water measured at 113.5-degree Fahrenheit. LAUNDRY: Laundry units are located in the garage area.
BEDROOMS: The LPA observed the residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.
Continues on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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 SHERMAN OAKS #1
FACILITY NUMBER: 195850191
VISIT DATE: 03/05/2025
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RESTROOMS: Restrooms were clean and sanitary and in operating condition with grab bars and non-skid mats. The hot water temperature was measured at 113.5 degrees Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing.

OUTDOOR SPACE: LPA observed the back patio which has a covered outdoor area for resident use. There are two gates on each side of the house designated for an emergency exits. The property is gated. There are no bodies of water on the premises.

RECORDS: Records review began at 11:30 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 11:55 a.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

The LPAs reviewed the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster
- Certificate of Liability of Insurance
- Emergency Drill Logs

No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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