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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005827
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:34:23 PM

Document Has Been Signed on 10/26/2021 12:34 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COZY HOME SENIOR CAREFACILITY NUMBER:
306005827
ADMINISTRATOR:DUMALIANG, CZARINA SFACILITY TYPE:
740
ADDRESS:22272 TERNITELEPHONE:
(949) 583-9365
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 5DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Czarina Dumaliang. AdministratorTIME COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA met with Czarina Dumaliang, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator began the tour of the inside and outside of the facility. There are currently five residents in care and there are no active covid-19 cases in the facility. LPA observed three residents in living room watching a movie and two residents in their bedrooms. All residents appeared to be clean and well taken care of. Upon entry LPA observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting the results. LPA observed the emergency disaster and evacuation plan. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All bathrooms observed to have supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and they appeared to be clean and sanitary. All bedrooms observed to have all the required components. Residents bedrooms are two private bedrooms with one resident per and two shared bedrooms with two residents per. Facility has back-up emergency food supply and water supply as well as PPE supplies in the attached garage. LPA toured the outside of the facility and observed shaded seating area for resident’s enjoyment. Area is used for visitation as well. The facility has completed the LIC808 Mitigation Plan, LPA reviewed the hard copy at the facility and approved the plan on today’s visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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