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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 04/12/2024
Date Signed: 04/12/2024 09:24:27 AM

Document Has Been Signed on 04/12/2024 09:24 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COTTAGE LLC, THEFACILITY NUMBER:
547202420
ADMINISTRATOR/
DIRECTOR:		THOMPSON, JENNIFERFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jennifer ThompsonTIME VISIT/
INSPECTION COMPLETED:
09:46 AM
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Licensing Program Analyst (LPA) L. Xiong conducted a Case Management visit for the purpose of Health and Safety check of residents in care. LPA observed two residents and one staff working during facility visit. LPA allowed entrance by Direct Care Staff, Lady Villanueva. 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 two (2) residents at the facility and was informed four (4) went to day program.

LPA obtained updated LIC 9020 (Register of Facility Clients/Residents) during the visit.

No deficiencies cited during this visit.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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