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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610672
Report Date: 10/28/2024
Date Signed: 10/28/2024 10:46:02 AM

Document Has Been Signed on 10/28/2024 10:46 AM - 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:CARING HOME COTTAGEFACILITY NUMBER:
197610672
ADMINISTRATOR/
DIRECTOR:		LOBO, FLORFACILITY TYPE:
740
ADDRESS:43728 GRANDPARK AVENUETELEPHONE:
(661) 802-4263
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 0DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Flor LoboTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection at this facility and met with the applicant representative Flor Lobo. The applicant is "CARING HOME COTTAGE". A fire clearance was approved on 07/30/2024 for six (6) ambulatory residents.

The facility is a single story house with a total of five (5) bedrooms and three (3) bathrooms. A tour of the physical plant was initiated at approximately 9:00 a.m. and the following was observed:
LPA observed required postings through out the facility.

KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of emergency and 7-day non perishable supply of food. Knives were observed locked in a kitchen drawer. Cleaning supplies and other toxins are stored in a locked cabinet.

BEDROOMS: There are five (5) bedrooms designated for residents' use, all but one (1) are private bedrooms. Residents' bedrooms were furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage.

BATHROOMS: The facility has three (3) shared bathrooms for residents' use. One bathroom is located in the shared bedroom. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at a range of 113°F to 114.3°F within regulation.

LAUNDRY ROOM: The laundry room is was observed locked. Laundry detergents and other cleaning agents were locked in the laundry room. The attached garage is through the laundry room. The garage is used to store extra facility supplies.



(continued on LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CARING HOME COTTAGE
FACILITY NUMBER: 197610672
VISIT DATE: 10/28/2024
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(continued from LIC 809)

Dual smoke/carbon monoxide alarms were tested and observed to be operable, they are hardwired and interconnected. Two (2) Fire extinguishers were observed fully charged with service date 07/25/2024.

COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and a couch that sit the capacity of the facility. The living room area was furnished with a television, a and a coffee table. There were no visible immediate hazards. There is a working telephone line and internet access to residents.

MEDICATIONS: The medication cabinet is located in a closet and was observed locked. A complete first aid kit is located in the medication closet.

Staff/Resident Records: Staff and resident records will be kept in the medication closet.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a covered patio and backyard furniture to accommodate the residents. The are drive way in front of the facility could park three (3) cars at one time.

Component III was conducted with the Licensee representatives.

Pre-Licensing is complete and this facility has no deficiencies. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
Exit interview conducted. Copy of this report.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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