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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 04/30/2024
Date Signed: 04/30/2024 04:41:42 PM

Document Has Been Signed on 04/30/2024 04:41 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/
DIRECTOR:		THOMPSON, JENNIFERFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 4DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:46 PM
MET WITH:Alicia LedesmaTIME VISIT/
INSPECTION COMPLETED:
05:02 PM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Annual Inspection. LPA met with staff Alicia Ledesma an spoke to Administrator Jennifer Thompson and inform her the purpose of the visit.

LPA toured the facility with staff. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents.

Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 12/2023. Water temperature observed to measure at 117 degrees F.

No deficiencies were observed.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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