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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320283
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:01:43 PM

Document Has Been Signed on 06/27/2024 04:01 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:VERNON COTTAGEFACILITY NUMBER:
198320283
ADMINISTRATOR/
DIRECTOR:		UMANA, JOSEFACILITY TYPE:
740
ADDRESS:2312 ROSWELL AVETELEPHONE:
(562) 342-6145
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 5DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:56 PM
MET WITH:Edgar Yraheta, Administrative AssistantTIME VISIT/
INSPECTION COMPLETED:
04:12 PM
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On 06/27/2024, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Edgar Yraheta, Administrative Assistant. The facility is licensed to operate for (6) non-ambulatory of which (1) may be bedridden elderly adults ages 60 and above. The facility is approved for (4) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (4) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside shaded seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 107.2 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were fully charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete.

Report continues, see LIC809C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VERNON COTTAGE
FACILITY NUMBER: 198320283
VISIT DATE: 06/27/2024
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The last emergency fire drill was conducted on 02/09/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 02/01/24 through 02/01/25.

An audit of two (2) residents (R1-R2) service files and four (4) staff (S1-S4) personnel files revealed to be complete. The facility has the current administrator's certification on file for Jose Umana.

There have been no deficiencies cited during today's visit.

An exit interview was held with Edgar Yraheta, Administrative Assistant, and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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