197609011-9-9-2025-31-AS-ERIS-DLCRYK-20250909132628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609011
Report Date: 09/09/2025
Date Signed: 09/09/2025 01:26:34 PM

Document Has Been Signed on 09/09/2025 01:26 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 COTTAGE		FACILITY NUMBER:	197609011
ADMINISTRATOR/ DIRECTOR:	GORY, MONICA		FACILITY TYPE:	740
ADDRESS:	43732 SENTRY LANE		TELEPHONE:	(661) 266-7995
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 3	DATE:	09/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:12 AM
MET WITH:	Monica Gory - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/09/2025 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual required visit. LPA was greeted by Staff #1 (S1) who granted access. S1 contacted the administrator, Monica Gory to let them know LPA was at the facility. LPA informed the administrator by telephone the purpose of the visit. Administrator met LPA shortly after. LPA reviewed the register of facility residents, and the staff schedule. LPA initiated a physical plant tour at approximately 10:20AM, and 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 such as linens. LPA observed a closet by room #4 that was locked. In the closet LPA observed emergency water, a first aid kit and residents' medication. 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, and nonskid matts. LPA observed proper fixtures such as grab bars. Hot water temperature was measured at 10:54AM in the bathroom closest to the bedrooms and it read 105 degrees Fahrenheit, within regulation. Common Areas: These include the living room and dining room. The areas were clean and clear of clutter. Passageways were free from obstructions. LPA did not observe any tripping hazards. The dining table and chairs sits the capacity of the facility. (Continue to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY COTTAGE	FACILITY NUMBER: 197609011
	VISIT DATE: 09/09/2025

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Kitchen: At 10:31AM LPA toured the kitchen. S1 was observed cleaning the area. The appliances used such as stove/oven, microwave, and refrigerator appeared functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility. LPA observed repackaged food properly labeled and in appropriate food storage containers. LPA observed fire extinguisher by the kitchen fully charged with purchase date 10/22/2024.

Garage/Laundry: The garage was observed locked. In the garage the facility stores supplies, has an extra refrigerator, deep freezer, washer and dryer. LPA also observed cleaning supplies and chemicals stored in the garage that is maintained locked. The washer and dryer were observed operable.

Backyard: The backyard is fenced in. LPA observed outdoor furniture and a patio with shade for residents. The backyard is sufficient in space for outdoor activities.

Records: LPA reviewed three (03) of three (03) resident records and three (03) staff records for compliance with licensing forms. LPA also reviewed facility's Emergency Disaster Plan(LIC610E) that was reviewed by administrator on 03/01/2025. The facility last conducted an emergency disaster fire drill on 07/22/2025. LPA reviewed the facility's Liability Insurance which is current.

Medication: Medication and Centrally Stored Medication Records were reviewed for accuracy and completeness.

LPA Rios observed the administrator test the dual smoke and carbon monoxide detectors at 12:52PM. They were observed operational through out the facility.

No deficiencies issued. Exit interview conducted. Report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

LIC809 (FAS) - (06/04)

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