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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607760
Report Date: 07/15/2022
Date Signed: 07/15/2022 09:17:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/15/2022 09:17 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COUNTRY COTTAGE IIFACILITY NUMBER:
197607760
ADMINISTRATOR:LOFTON, JANICEFACILITY TYPE:
740
ADDRESS:5302 W 119TH STTELEPHONE:
(310) 722-7541
CITY:INGLEWOODSTATE: CAZIP CODE:
90304
CAPACITY: 3CENSUS: 3DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Brenda ChandlerTIME COMPLETED:
12:37 PM
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On 07/15/22, Licensing Program Analysts (LPAs) Ernand Dabuet and Perry Scott conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with licensee Brenda Chandler and explained the purpose of today’s visit. The facility is licensed to operate for (3) developmentally disabled elderly adults. The facility is cleared for 3 non-ambulatory. The consumers are Westside Regional Center residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPAs and licensee toured the physical plant. There were no obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 116.4 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has two (2) fire extinguisher that were charged, smoke detectors, and carbon monoxide were operable. LPA Scott reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. A working landline telephone remains available. An emergency fire drill was conducted on 06/22/22.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY COTTAGE II
FACILITY NUMBER: 197607760
VISIT DATE: 07/15/2022
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INFECTION CONTROL

During the visit, LPAs observed the facility's infection control practices. LPAs observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPAs observed staff wearing face coverings, LPAs observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident vaccination records, test results, and daily temperature screening. The facility has an approved CCLD Mitigation Plan. The facility has submitted an Infection Control Plan to the regional office.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Kim Post .
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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