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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605964
Report Date: 03/04/2022
Date Signed: 03/04/2022 12:02:47 PM

Document Has Been Signed on 03/04/2022 12:02 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COTTAGE, THEFACILITY NUMBER:
197605964
ADMINISTRATOR:CHRIS GUTIERREZFACILITY TYPE:
740
ADDRESS:1258 N. SIERRA BONITA AVENUETELEPHONE:
(626) 794-9585
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Linda Morales, Licensee
Stacy Lopez, Lead manager		TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Linda Morales, Licensee and Stacy Lopez, lead manager who assisted with visit. The facility has a capacity of six (6) residents. It is licensed to serve six (6) bedridden residents age 60 and above. Facility approved for one (1 ) hospice waiver. Linda Morales was informed of the annual licensing fees being overdue. Prior to LPA's departure, Mrs. Morales submitted on-line payment for the licensing fees and provided confirmation to LPA. Administrator certificate is current and the expiration date is 01/03/23.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is located in a residential neighborhood. The property ground is a duplex lot with two (2) facilities. The front house is facility, Con Carino, and the back house is The Cottage. The Cottage facility has four (4) bedrooms, two (2) bathrooms, living room, dining room, kitchen, front yard, and backyard area. Facility has an attached garage that is locked and utilized for additional storage of items.

A physical tour was conducted. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Adequate linen and personal hygiene supplies was observed.
(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COTTAGE, THE
FACILITY NUMBER: 197605964
VISIT DATE: 03/04/2022
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No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Carbon monoxide devices are combined with smoke detectors and operable. Fire extinguishers are fully charged.

Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

Deficiency was observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report is discussed and provided to facility Licensee /Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2022 12:02 PM - It Cannot Be Edited


Created By: Bonnie Tao On 03/04/2022 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COTTAGE, THE
FACILITY NUMBER: 197605964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F.

This requirement is not met as evidenced by:

During today's visit, LPA obtained the following water temperature is 137 degrees F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2022
Plan of Correction
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Licensee will adjust the water heater to the temperature in a range of 105- 120 degree F by the POC due date. Licensee will send picture of the water temperature reading to Licensing by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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