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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603249
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:45:03 PM

Document Has Been Signed on 02/14/2024 02:45 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:CERVATO COTTAGEFACILITY NUMBER:
198603249
ADMINISTRATOR:UMANA, JOSEFACILITY TYPE:
740
ADDRESS:4622 E. CERVATO STREETTELEPHONE:
(818) 606-6136
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Administrator Jose UmanaTIME COMPLETED:
03:00 PM
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On 02/14/24 Licensing Program Analysts (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Jose Umana as the purpose of todays visit was explained. The facility is licensed to operate for 6 ambulatory residents of which 6 can be non-ambulatory, ages 60 and over and is approved hospice waiver for 6 residents. Current facility census is 5. Liability insurance is active, upcoming facility fee information provided.

The facility is a single-story structure located in a residential neighborhood and consists of the following: 6 bedrooms, 2 common restrooms, 1 private restroom, laundry room, dining area, kitchen, pantry, linen closet, 1 staff office area and a designated outdoor shaded area. The facility water temperatures measured between 105- and 120 degrees F. The facility has a working landline telephone.

There were no bodies of water, no weapons or obstructions on the premises. Resident rooms were inspected, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. All bathrooms were found to be within Title 22 regulations and were clean and operational. All storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 12/15/23, 2 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Exit interview conducted with Administrator Jose Umana, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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