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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610364
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:00:39 PM

Document Has Been Signed on 02/20/2025 01:00 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANITA'S COTTAGEFACILITY NUMBER:
197610364
ADMINISTRATOR/
DIRECTOR:		GURULE, MARIOFACILITY TYPE:
740
ADDRESS:27736 SYCAMORE CREEK ROADTELEPHONE:
(818) 667-8166
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 5CENSUS: 3DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Mario GuruleTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection, LPA was greeted by caregiver Nazrul Sekh, who allowed LPA to enter. There was (1) additional staff on duty, and the Administrator Mario Gurule was contacted and on the way to the facility. The current census is (3). Facility license/sketch, grievance/complaint procedures, personal rights, Infection/Mitigation plan, Administrator certificate, emergency disaster plan, COVID/hand-washing signs, and complaint procedures was visibly posted.

A physical plant tour of the facility inside and outside was conducted with staff. The following common areas: living, dining, kitchen, resident bedrooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen: LPA observed a Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator and freezer stocked with food in the garage. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, that are stored in the kitchen and garage area were locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (5) bedrooms; with (1) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available; as well as personal hygiene products available for residents.

Bathrooms: There are (2); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at degrees 119.5 Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. All exit doors have alarms; all were operating. Fire extinguisher was checked. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANITA'S COTTAGE
FACILITY NUMBER: 197610364
VISIT DATE: 02/20/2025
NARRATIVE
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 Record review: Staff was missing medication and current training records. Residents: All required documents observed in file and current.

Citations issued, appeal rights, and copy of report provided to Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/20/2025 01:00 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 02/20/2025 at 12:36 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANITA'S COTTAGE
FACILITY NUMBER: 197610364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection, both staff records reviewed, (2) files, did not have current/yearly training. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
Plan of Correction
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Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection, both staff records reviewed, (2) files, did not have current/yearly training. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
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.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/20/2025 01:00 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 02/20/2025 at 12:36 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANITA'S COTTAGE
FACILITY NUMBER: 197610364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection, both staff records reviewed, (2) files, did not have current medication training. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
Plan of Correction
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Type B
Section Cited
HSC
1569.69(d)
Other Provisions
(d) Each residential care facility for the elderly that provides employee training under this section shall use the training material and the accompanying examination that are developed by, or in consultation with, a licensed nurse, pharmacist, or physician. The licensed residential care facility for the elderly shall maintain the following documentation for each medical consultant used to develop the training:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection, both staff records reviewed, (2) files, did not have medication training. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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