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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605964
Report Date: 05/23/2024
Date Signed: 06/28/2024 10:18:00 AM

Document Has Been Signed on 06/28/2024 10:18 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COTTAGE, THEFACILITY NUMBER:
197605964
ADMINISTRATOR/
DIRECTOR:		CHRIS GUTIERREZFACILITY TYPE:
740
ADDRESS:1258 N. SIERRA BONITA AVENUETELEPHONE:
(626) 794-9585
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 3DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Linda Morales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced Annual Required Visit on 05/23/24 at 9:05 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for six (6) bedridden residents. LPA Vaid requested and obtained copies of Personnel Report (LIC 500), Resident Roster (LIC 9020). Staff #2(S2) arrived shortly after.

LPA OBSERVATIONS: Tour began at 9:18 am and was led by S2. The facility is a single-story building located in a residential area with three (3) resident bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.
Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Vaid observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Vaid observed knives and sharps located kitchen cabinet, to be inaccessible to three (3) out of three (3) residents in care. LPA Vaid observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to three (3) out of three (3) residents in care. Kitchen sink water temperature was measured at 106.4 degrees F. Kitchen appliances were observed to be clean and in working order. LPA Vaid observed fully charged fire extinguisher.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 3: LPA Vaid observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Vaid observed required auditory devices on exits.
con't on LIC 809C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COTTAGE, THE
FACILITY NUMBER: 197605964
VISIT DATE: 05/23/2024
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Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 108.3 degrees F which is within the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 107.3 degrees F which is within the required 105 – 120 degrees F.

Centrally Stored Medications: LPA observed cabinet located in hallway to locked and inaccessible to residents in care. Two (2) resident medication was reviewed.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Emergency Drills: Proof of last documented fire drill was conducted 04/04/24.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and observed posted Emergency Disaster Plan.

Staff Personnel Files: Staff files are maintained at facility. Three (3) staff files were reviewed.

Resident Files: Three (3) resident files were reviewed. Admissions agreements, Health Screening, and resident personal rights were observed in files.

Liability Insurance & Infection Control Plan: Liability Insurance expires 10/17/2024, and Infection Control Plan was reviewed.

No deficiencies were found during visit. Exit interview was conducted with staff S1 and a copy of this report, were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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