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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609011
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:51:18 PM

Document Has Been Signed on 09/10/2024 04:51 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:STRAWBERRY COTTAGEFACILITY NUMBER:
197609011
ADMINISTRATOR/
DIRECTOR:		GORY, MONICAFACILITY TYPE:
740
ADDRESS:43732 SENTRY LANETELEPHONE:
(661) 266-7995
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 5DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Monica GoryTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 09/10/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual required visit. LPA was greeted by Staff #4 (S4) who granted access. S4 contacted the administrator, Monica Gory to let them know LPA was at the facility. Administrator met LPA shortly after. LPA explained the purpose of the visit. This is a Residential Care Facility for the Elderly licensed for six (6) residents of which five (5) may be non-ambulatory and one (1) may be bedridden. Facility has been approved for a hospice waiver for two (2).

LPA reviewed the register of facility residents, and the staff schedule. LPA initiated a physical plant tour at 1:40 p.m. the following was observed:

Bedrooms: There are four (4) total bedrooms for resident use. Two (2) out of the four (4) bedrooms are designated to be shared. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. LPA observed hallway cabinets used as storage for facility supplies.

Bathrooms: There are three (3) bathrooms. One (1) bathroom is located in a shared bedroom for private use. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. Hot water temperature was measured at 2:00 p.m. and was within regulation.

Kitchen: The kitchen appliances and fixtures appeared functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. LPA observed fresh fruit and resealed food properly labeled.

Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff or resident records or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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