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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607071
Report Date: 08/18/2025
Date Signed: 08/18/2025 02:13:52 PM

Document Has Been Signed on 08/18/2025 02:13 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:CHLOIE'S COTTAGEFACILITY NUMBER:
197607071
ADMINISTRATOR/
DIRECTOR:		LINDA RENARDFACILITY TYPE:
740
ADDRESS:747 N. BELLEVIEW AVENUETELEPHONE:
(909) 599-3193
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 6DATE:
08/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Fe Abejo - Caregiver TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual inspection visit using the CARE tool. LPA met with Fe Abejo Caregiver and explained the reason for the visit.

The facility is licensed to serve (6) elderly residents age 60 and above of which all may be non-ambulatory, and a hospice waiver for (3). The facility is located in a residential area and consist of a single home with a kitchen, dining room, living room, (3) resident bedrooms, (2) bathrooms, an office space, staff room,laundry/storage space, and a backyard.

The following domains were reviewed during this visit:
Infection Control: Facility maintains a copy of infection control and was last reviewed on 7/1/25. All staff have a TB clearance.
Operational Requirements: Facility maintains a plan of operation, infection control plan, fire clearance. Facility is operating within the limitations of their license. They currently don't have residents under hospice care. A current liability insurance was observed and a copy was obtained.
Physical Plant/Environmental Safety: LPA toured the facility with Fe Abejo caregiver and observed the following. Facility was observed in good repair. Living room has a fireplace with a metal cover and it is furnished. Dining room was observed with furniture and in good repair. Kitchen was observed clean, a large pair of scissors was observed in a small drawer without a lock which was moved by staff to a drawer with a lock which was unlock at the time of the visit were knives and sharps are stored. Refrigerator/freezer and pantry were observed. Medication cabinet is located in the kitchen area. Passage ways were observed clear of obstructions. Back porch and side porch were observed with old furniture clutter around, A ripped chair cushion chair was also observed. Garage space has been converted into an office space, a staff room, and laundry/storage area. (CONT. 809C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2025
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: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 08/18/2025
NARRATIVE
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Three (3) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Room #1 and #2 were each observed with one bed with two half bed rails combine making it a full bed rail, and a bed with a full bed rail and Room #3 was observed with 3/4 bed rails in each bed. Door in bedroom #2 leading to a passage way which exits the facility did not have a sound device. Sound device was not working at the time of the tour on door exiting to back porch which leads to outside passageway. Two (2) bathrooms were observed in good repair, however shower floors were observed with soap buildup and mold in the corners. Water temperature was tested in each bathroom sink and tested between 112.8-114.2 degrees F., which is within the required 105-120 degrees F. There are no large bodies of water at the facility. Carbon Monoxide/Smoke detectors were tested and are in working condition. A fire extinguisher was observed.
Staffing: Administrator certificate was reviewed for Linda Renard #7008248740 exp. date: 5/3/25. CPR/First aid training was observed for staff. A living 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. Two staff were interviewed.
Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the entrance of the home.
Planned Activities: Facility provides activities such as board games, puzzles, books and music and crafts provider.
Food Services: Although LPA did not observed a variety of food supplies, facility has at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the storage area. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored in storage space. Staff were observed practicing hygiene and infection prevention. Four out of five 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 5 residents.
Resident Records/Incident Reports: LPAs reviewed 5 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal, 3 out of 5 residents did not have a medical assessment within the last 12 months. Three residents were interviewed.
Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 7/1/25. Emergency drills are conducted quarterly, last emergency drill was conducted on 7/2/25.
(CONT. 809C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
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: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 08/18/2025
NARRATIVE
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Residents with Special Health Needs: Facility is only serving 1 resident on Home Health Care, no bedridden, no hospice residents.

Assistant Administrator Iren Creighton notified LPA that the facility is going under a change of ownership.

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

Exit interview was conducted with Iren Creighton Assistant Administrator 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: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2025 02:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/18/2025 at 01:35 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: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 a pair of large scissors, and knives/sharps were observed accessibel to the residents in unlock kitchen drawers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Administrator will provide in-service training to staff and will submit a copy of trainig log, that includes training topic, date, time, and signatures by POC due date 8/19/25.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 4 out of 6 residents' beds were observed with full bed rails (2 were made full with half bed rails combine) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Administrator will change full bed rails to 3/4 bed rails and submit a picture to the department by POC due date 8/19/25.
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: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/18/2025 02:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/18/2025 at 01:35 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: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 shower floors in both bathrooms were observed with soap buildup and mold, clutter of old furniture was observed in the back porch and side porch, and a ripped cushion was observed in a chair in the back porch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2025
Plan of Correction
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Administrator will submit pictures to the department of clean showers, and remove the clutter to the deparment by POC due date 8/25/25.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (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, the licensee did not comply with the section cited above in 6 out of 6 residents were observed with bed rails (4 with full bed rails and 2 with 3/4 bed rails) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2025
Plan of Correction
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Administrator will obtain a physician's order for resident #1-6 and submit a copy to the department or remove bed rails by 8/25/25.
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: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2025 02:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/18/2025 at 01:47 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: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(d)
87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.

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 2 out of 3 exit doors do not have a working auditory device which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Administrator will ensure each auditory device is in working condition and will submit a picture/video of working auditory devices to the department by POC due date 8/19/25.
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: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2025


LIC809 (FAS) - (06/04)
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