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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603249
Report Date: 02/12/2025
Date Signed: 02/12/2025 01:49:37 PM

Document Has Been Signed on 02/12/2025 01:49 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/
DIRECTOR:		UMANA, JOSEFACILITY TYPE:
740
ADDRESS:4622 E. CERVATO STREETTELEPHONE:
(818) 606-6136
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 6DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH:Jose UmanaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On February 12, 2025 Licensing Program Analyst (LPA) Deborah Lee arrived at facility to 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. There are 2 residents currently on hospice. Current facility census is 6. Licensing fee status discussed with Administrator at time of visit.

Structure: 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 has a working landline telephone.

Physical Plant LPA and Administrator Jose Umana toured the facility inside and outside. LPA observed 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. LPA observed that facility had required postings: Facility license, personal rights, ombudsman information poster, facility sketch, exit signs, infectious disease postings, Administrator certificates, an emergency disaster plan.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CERVATO COTTAGE
FACILITY NUMBER: 198603249
VISIT DATE: 02/12/2025
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Bedrooms LPA inspected all (6) bedrooms All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. The water temperature measured 110.8 degrees Fahrenheit. All bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in hall closet. .

Kitchen LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, refrigerator. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked cabinet under the sink and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. There is a laundry room where the washer and dryer are located. The detergent and other cleaning supplies are locked in a cabinet inaccessible to residents in care.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CERVATO COTTAGE
FACILITY NUMBER: 198603249
VISIT DATE: 02/12/2025
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Safety LPA observed and tested smoke/carbon monoxide combo detectors to be fully operable. LPA observed ( 2) fully charged fire extinguishers that was last serviced on 5/16/24. The last emergency drill was conducted on 12/12/24. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids. LPA observed all exits to be clear and easily accessible. All toxins locked and inaccessible to residents in care.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet that is inaccessible to Residents in care.

Files LPA reviewed ( 4 ) resident files and found that (4) out of (4) contained all the necessary documentation. LPA reviewed (4) staff files and found that (4) out of (4) contained the required documentation, certification, and training. Liability Insurance expires on 02/01/2026.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff.

Outside area: During visit LPA observed the outside grounds (front and back) to be free of clutter, debris, and passage ways were free of obstruction.

There were no deficiencies cited during today’s visit. Exit interview conduct and report provided to Administrator Jose Umana.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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