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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610672
Report Date: 10/15/2025
Date Signed: 10/15/2025 12:57:58 PM

Document Has Been Signed on 10/15/2025 12:57 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.RO, 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: 3DATE:
10/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Flor Lobo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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At 10:15 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator, Flor Lobo. LPA explained the purpose of the visit. LPA observed required postings in the entry area and accessible hand sanitizer, gloves, and masks for visitors. LPA was asked to sign in the visitors log and take their temperature. This is a Residential Care Facility for the Elderly (RCFE). A fire clearance was approved on 01/03/2025 for two (2) ambulatory and four (04) non ambulatory residents.

At 10:20 a.m., LPA initiated a physical plant tour of the inside and outside of the facility. The following observations were made:
At 10:22 a.m., LPA observed the administrator test the hard wired, interconnected, dual smoke and carbon monoxide detectors. Smoke and carbon monoxide detectors were observed to be functioning properly.
Kitchen: The kitchen appliances and fixtures appeared functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility. LPA observed some repackaged food that was properly stored in clearly labeled, containers. LPA observed knives and sharps locked in a kitchen drawer inaccessible to residents. The fire extinguisher is located in the kitchen and was observed fully charged with service date 06/02/2025.

Common Areas: These included the living area and dining area. The common areas were properly furnished. The couches and the dining table sits the capacity of the facility and were observed in good repair. A fireplace in the living area was properly screened. LPA observed a facility telephone accessible to residents. Overall the facility was clean and clear of clutter. (Continue on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING HOME COTTAGE
FACILITY NUMBER: 197610672
VISIT DATE: 10/15/2025
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(Continued form LIC809) Bedrooms: There are a total of five (5) resident bedrooms, one (1) of which is shared. Bedrooms were furnished with beds, night stands, chairs, appropriate bedding and linens, and sufficient lighting. Rooms with exit doors had auditory alarms that were observed on and functioning properly. LPA did not observe any tripping hazards.

Bathrooms: There are three (3) bathrooms designated for resident use. One (1) is located in a shared bedroom. Bathrooms were properly supplied with hand soap, toilet paper and paper towels. LPA observed non skid matts or non skid shower floors and grab bars. Hot water temperature was taken from one (1) bathroom at 10:43 a.m. and read between 113.9 degrees Fahrenheit. LPA observed night lights in bathrooms, bedrooms and the hallways leading to the bathrooms.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. The laundry room leads to the attached garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the garage locked. In the garage LPA observe a deep freezer and emergency food and water.

Facility / Staff / Resident Files: At approximately 10:56 a.m., LPA conducted a file review of four (4) staff records and three (03) out of three (03) resident records to insure compliance of licensing forms. LPA also reviewed the facility's active Certificate of Liability Insurance, Emergency Disaster Plan and Infection Control Plan reviewed by administrator on 10/01/2025. Facility had conducted a disaster drill with staff regarding power failure, fire and bomb threats on 08/10/2025 and have scheduled to participate for the national Shake Out drill on 11/01/2025 to complete their Q4 drill. LPA's review of LIC500 indicated their is coverage 24/7.

LPA observed centrally stored medication, first aid kit and records are stored in a locked closet. At approximately 11:49 a.m., LPA reviewed Centrally Stored Medication Records for completeness. Facility also keeps a Medication Administration Records (MAR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit interview conducted. Copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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