306005827-12-1-2022-22-AS-RMAZ-CLPPXR-20221201104246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005827
Report Date: 12/01/2022
Date Signed: 12/01/2022 10:42:49 AM

Document Has Been Signed on 12/01/2022 10:42 AM - 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 CARE		FACILITY NUMBER:	306005827
ADMINISTRATOR:	DUMALIANG, CZARINA S		FACILITY TYPE:	740
ADDRESS:	22272 TERNI		TELEPHONE:	(949) 583-9365
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6		CENSUS: 6	DATE:	12/01/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Czarina Dumaliang		TIME COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of conducting a POC inspection to verify correction of citations issued during visit conducted on 11/23/2022. LPA arrived at facility was greeted at the door by Czarina Dumaliang, Administrator and granted entry. LPA met with Administrator and explained the nature of the visit.

LPA toured the facility and tested the smoke detectors which were operational. LPA inspected facility bathroom and observed the toilet to have been repaired and in working condition.

Based upon this inspection, LPA observed the following:

*Deficiency cited under Title 22 Regulation 87203 has been cleared. Licensee complied with the terms of the POC by POC due date.

*Deficiency cited under Title 22 Regulation 87303(e)(6) has been cleared. Licensee complied with the terms of the POC by POC due date.

*Deficiency cited under Title 22 Regulation 87355(e)(2) has been cleared. Licensee complied with the terms of the POC by POC due date.

LPA generated letter of deficiency citations cleared and provided copy to Administrator. Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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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