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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605964
Report Date: 08/19/2025
Date Signed: 08/19/2025 01:01:08 PM

Document Has Been Signed on 08/19/2025 01:01 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
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:
08/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Jessica Lopez - CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jessica Lopez caregiver and explained the reason for the visit.

The facility is licensed to serve (6) bedridden residents ages 60 and over. The facility is located in a residential area behind another home, and consist of a dining room, living room, kitchen, (3) resident bedrooms, (2) resident bathrooms, a back yard, a garage, and a shared front yard and laundry area.

The following domains were reviewed during this visit:
Infection Control: Facility does not have a copy of infection control. All staff have a TB clearance.
Operational Requirements: Facility maintains a plan of operation, fire clearance. Facility is operating within the limitations of their license. They currently don't one resident under hospice care. A current liability insurance was observed and a copy was obtained.
Physical Plant/Environmental Safety: LPA toured the facility with Jessica Lopez caregiver and observed the following. Facility was observed in good repair. Living room and dining room were observed with furniture and in good repair. Kitchen was observed clean. Cleaning supplies and sharps are maintained in a locked cabinet. Refrigerator/freezer and pantry were observed. Medication cabinet is located in hallway. Three (3) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Exit doors in each bedroom exiting the facility have a sound device that were observed not working at the time of the visit. Bed rails were observed in each residents' bed. Resident #1 and #3 have 3/4 bed rails and there is no physician's request on file. Two (2) bathrooms were observed in good repair and clean. Water temperature was tested in each bathroom sink and tested between 66.7 - 103.4 degrees F., which is not within the required 105-120 degrees F. (CONTINUED ON LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/19/2025
NARRATIVE
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There are no large bodies of water at the facility. Carbon Monoxide/Smoke detectors were tested and are in working condition. Passage ways were observed clear of obstructions. Backyard and front yard were observed with shaded seating area.
Staffing: Administrator certificate was reviewed for Chris Gutierrez was not available. LPA checked on the department's website and did not find a request for renewal. Linda Morales has an administrator certificate which is pending for renewal and is the responsible person. CPR/First aid training was observed for staff. Staff is on duty during the night shift.
Personnel Records/Staff Training: LPA reviewed 5 staff files. Files were available for review. Files include; TB clearance, health screening, background clearance, personnel record, and training for each staff. Staff #4 does not have a health screening on file. Staff #5 is not associated to the facility and has been working since 10/20/25. Three staff were interviewed.
Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted throughout the home.
Planned Activities: Facility provides activities such as puzzles, books and interactive dolls.
Food Services: LPA observed at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the laundry area. Kitchen was observed clean and free of pest. Staff were observed practicing hygiene and infection prevention. Two out of three residents have a modified diet per medical assessments.
Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in locked medication cabinet. LPA reviewed medication for 3 residents.
Resident Records/Incident Reports: LPA reviewed 3 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal. One resident was interviewed.
Disaster Preparedness: LPA reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 5/25/24. Emergency drills are conducted monthly, last emergency drill was conducted on 7/14/25.
Residents with Special Health Needs: Facility is serving 1 resident on hospice, resident #1. No bedridden.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Stacy Lopez Manager and a copy of this report, LIC 809D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/19/2025 01:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/19/2025 at 12:08 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature tested at 103.4 degrees F., in bathroom #1 and at 66.7 degrees F. in bathroom #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator will adjust water temperature and maintain a daily water temperature log which will be submitted to the department by POC due date 8/26/25.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff #4 does not have a health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator will have staff #4 obtain a health screening and submit a copy to the department by POC due date 8/26/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/19/2025 01:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/19/2025 at 12:08 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in residetn #1 is currently on hospice and the facility does not have a hospice waiver which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator will submit a hospice waiver request for the facility or request a hospice exception for resident #1 to the department by POC due date 8/26/25.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, ...(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in resident#1 and #3 do not have a physician's order for bed rails on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator will request physician's orders for bed rail for Resident #1 and #3 and submit a copy to the department by POC due date 8/26/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/19/2025 01:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/19/2025 at 12:32 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in staff #5 is not associated to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Administrator will ensure staff #5 is associated to the facility and will submit a copy of guardian roster to the department by POC due date 8/20/25.
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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