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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:04:26 PM

Document Has Been Signed on 08/29/2022 03:04 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COTTAGE LLC, THEFACILITY NUMBER:
547202420
ADMINISTRATOR:SIEGEL, DELENAFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
08/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Diana BradleyTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) M. Medina conducted a Case Management visit for the purpose of Health and Safety check of residents in care. LPA observed four staff working during facility visit. LPA allowed entrance by Direct Care Staff, Terry Overstreet. Per staff, there is currently one (1) resident receiving hospice services and no home health services.

A tour of the facility was conducted. Adequate food supply to meet the needs of residents. Facility observed to be clean and odor free. Facility temperature comfortable.

LPA observed five (5) residents participating in day program activities at dining room table and one (1 ) resident relaxing in their room.

LPA received updated LIC 9020 (Register of Facility Clients/Residents) and LIC 308 (Designation of Administrative Responsibility) during Case Management visit.

No deficiencies cited during this visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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