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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005827
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:57:47 PM

Document Has Been Signed on 11/07/2024 03:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COZY HOME SENIOR CAREFACILITY NUMBER:
306005827
ADMINISTRATOR/
DIRECTOR:
DUMALIANG, CZARINA SFACILITY TYPE:
740
ADDRESS:22272 TERNITELEPHONE:
(949) 583-9365
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Serparis DumaliangTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPAs) Ruth Martinez and Nancy Guillen are conducting this unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and were greeted and granted entry by caregiver and LPAs explained the nature of the visit. There are six residents at the facility and there is one resident receiving hospice services currently.

LPAs began the tour of the inside and outside of the facility. LPAs observed resident in the living room watching TV. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage a cabinet and refrigerator located in the garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs observed a lock box in the refrigerator with resident medication. LPAs observed a first aid kit located with medication. LPAs inspected the bathroom and LPAs measured the hot water temperature which measured 115.5 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Facility lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants were stored locked underneath kitchen sink and locked in hallways storage closet. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms which had sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed there are shaded seating areas for residents’

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COZY HOME SENIOR CARE
FACILITY NUMBER: 306005827
VISIT DATE: 11/07/2024
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enjoyment. LPAs observed a fire extinguisher with service date of November 2023, in kitchen. LPAs verified fire drills are conducted. LPAs began review of records. LPAs reviewed six resident records. All the required documentation was present and current in the residents’ files reviewed. LPAs reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPAs observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected 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: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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