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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605964
Report Date: 02/13/2023
Date Signed: 02/13/2023 02:20:30 PM

Document Has Been Signed on 02/13/2023 02:20 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
GREATER LA AC/SC, 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: 3DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Linda MoralesTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Yanette Abzun, Caregiver and discussed the purpose of today's visit. Shortly after, the Administrators Stacy Lopez-Santa Ana and Linda Morales arrived and assisted with the inspection. The facility is licensed to serve six (6) bedridden residents ages 60 and over. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and PPE supplies. This single story home contains three (3) bedrooms, two (2) bathrooms, office, a living room, kitchen, dining area, backyard, and detached garage.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • LPA observed that Staff was wearing a face covering/mask
  • Staff screened and took the temperature of LPA upon arrival.
  • Covid-19 signage are posted at the facility.
  • Facility maintained a 30-day supply of PPE located in the supply closet in the office.
  • The kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and working properly.
  • The laundry room is located outside the home and is clean and has all cleaning supplies locked in a cabinet and inaccessible to residents.
  • Cleaning solutions and sharps were locked in a cabinet in the kitchen area and inaccessible to residents.
  • Water temperature was measured in kitchen and bathrooms. Hot water in the kitchen read 106.3 deg F, Bathroom #1 read 105.2 deg F and all areas measured within the required 105 - 120 degrees.
  • Residents bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms have the required grabs bars and contained hygiene supplies including liquid soap, paper towels and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Residents' medications were reviewed to confirm medication is given as prescribed and is documented properly.
  • The common areas such as living room and dining room are clean and have the required furniture.
  • The backyard has a shaded and sitting area. LPA observed large, unused items sitting in the backyard which blocks the access to the side yard.
  • A fire extinguisher was observed to be fully charged and last serviced on 3/10/2022.
  • There were no cameras and bodies of water on the premises.
  • Smoke detectors/carbon monoxide detectors and auditory devices on exit points were present and operable.
  • Staff and clients files were not reviewed during the visit.
  • Administrator, Chris Gutierrez's certificate expires on 8/15/2024. Co-Administrator Linda Morales's certificate expired on 1/03/2023 and had sent the renewal on 1/31/2023. Renewal certificate has not been received as of yet. Proof of submission was provided to LPA during the visit.


Pursuant to Title 22, deficiency was cited on the attached 809-D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator, Linda Morales.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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Document Has Been Signed on 02/13/2023 02:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/13/2023 at 02:07 PM
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: 02/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in that large, unused items were observed to be sitting in the backyard, and blocking the access to the sideyard which poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 02/20/2023
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023


LIC809 (FAS) - (06/04)
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