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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610364
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:50:58 PM

Document Has Been Signed on 02/09/2023 03:50 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANITA'S COTTAGEFACILITY NUMBER:
197610364
ADMINISTRATOR:GURULE, MARIOFACILITY TYPE:
740
ADDRESS:27736 SYCAMORE CREEK ROADTELEPHONE:
(818) 667-8166
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 5CENSUS: 4DATE:
02/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mario Gurule, AdministratorTIME COMPLETED:
04:20 PM
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At 12:00pm, Licensing Program Analyst (LPAs) Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with applicant, Mario Gurule. This is a change of ownership application from (Facility #197607032) to (Facility #197610364). LPA conducted an entrance interview with the Administrator. At the time of this visit LPA observed and assessed four (4) residents present in the facility. All residents appear to be clean and groomed. Fire Clearance dated 11/30/22 was received for five (5) non-ambulatory residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with Rules and Regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has a total of five (5) bedrooms, four (4) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked cabinet in the living room area. At 2:20pm, the hot water was tested and measured at 120°F. At 2:15pm, LPA observed medications are stored in a locked kitchen cabinet. The fire extinguisher is also located in the kitchen and was last purchased on 03/18/22. Smoke detectors were located throughout the facility, and at 2:45pm they were tested and observed to be operational. Carbon monoxide was located in the living room area, by the kitchen and was also tested and observed to be operational. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance wall with other posting requirements. The first aid kit is readily available. Facility appears to be clean, in good repair

Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANITA'S COTTAGE
FACILITY NUMBER: 197610364
VISIT DATE: 02/09/2023
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and kept at a comfortable temperature of 76°F. Appliances in the kitchen appeared to be functional.

Facility appears to be clean, in good repair and kept at a comfortable temperature of 76°F. Appliances in the kitchen appeared to be functional. LPA observed enough sufficient supply of 2 days perishable foods and one week of non-perishable foods on premises. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors. Plan of operation for dementia residents was also discussed with the Administrator.


There is a shaded sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The attached garage is kept locked. The garage is currently being used for perishable and non-perishable food storage and storage. At approximately, 2:40pm LPA toured through the laundry area and observed all chemicals and cleaning supplies area locked and inaccessible to residents in care.

Component III was conducted with the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Administrator Mario Gurule and a copy of this report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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