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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 04/13/2026
Date Signed: 04/29/2026 04:15:44 PM

Document Has Been Signed on 04/29/2026 04:15 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COTTAGE INC, THEFACILITY NUMBER:
547202420
ADMINISTRATOR/
DIRECTOR:		THOMPSON, JENNIFERFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
04/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:38 AM
MET WITH:Amber LandTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) B. Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA introduced themselves and was allowed entrance into the facility. LPA met with Amber Land.

Facility is licensed for 6 residents and has a current census of 6. There are 2 residents on hospice and they are also receiving home health care through hospice. Plans are current, but facility was not able to provide staff training on Hospice Care Plans. Water temperature was checked in the kitchen which read at 113.5 degrees Fahrenheit. Fire Extinguisher was serviced November 18, 2025 and is within the safety regulation period. Smoke detectors were tested and in working order. Facility does not have carbon monoxide detectors. Facility has kitchen knives stored with cleaning supplies under the sink. Kitchen cabinet has a glue trap stored with clean dishes

Administrator Jennifer Thompson is no longer at the facility since February 2026. Currently there is not a qualified administrator in the facility. Staff Amber Land is working on obtaining RCFE Administrator's Certificate. Staff files were reviewed, are not complete. Staff training was conducted by Jennifer Thompson who was not certified as an RCFE Administrator, but as an ARF Administrator. Training verification was missing information regarding explanation of training conducted and hours completed for training. Resident files were reviewed and incomplete. Resident files are missing current and complete physician reports, appraisals/re-appraisals for change in condition. Facility could not provide a log for disaster drills that are conducted quarterly. Facility could not provide a disaster plan or infection control plan. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications. Hygiene products are accessible to resident’s in care; R1’s physician's report indicated R1 is at risk if hygiene products are accessible.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420
VISIT DATE: 04/13/2026
NARRATIVE
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LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms, bathrooms, medication storage, kitchen, and outdoor areas. Back fence has a gate making facility accessible to neighbors. Bedrooms were clean, properly furnished, with adequate lighting, and in good repair. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Deficiencies observed during today's inspection were cited per California Code of Regulations, Title 22.

Owner/operator Howard Ferguson is not listed on the staff roster; follow-up visit may be warranted at a later time to issue citations. Any other deficiencies not cited during today's visit could warrant follow-up visit to cite at a later time.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing by April 24, 2026.

Exit interview conducted and a copy of this report LIC809, LIC809Ds, and appeal rights were provided to Amber Land.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above due to facility not have a carbon monoxide detector in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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4
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above due to having kitchen knives under the sink along with cleaning supplies. There is also a glue trap placed with clean dishes which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to R3 having 3 medications that were not listed in the centrally stored medication log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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Facility will complete Centrally Stored Medication Log for R3 and provided corrected verification to the Dept by POC due date.
Type A
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above in 5 out of 6 resident's P&I logs were off count, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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Facility will write a statement regarding when inventory will be completed with the due date. Statement will be sent to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.605
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview & record review, the licensee did not comply with the section cited above due to facility not having current liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Facility will provided verification of liability insurance to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87216(a)
Bonding
(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to facility not having a current surety bond, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Facility will provided verification of surety bond to the Dept by POC due date.
Type B
Section Cited
HSC
1569.153(a)
Licensing
(a) Establishment and posting of the facility’s policy regarding theft and investigative procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to the facility not having theft and investigation procedures posted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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2
3
4
Facility will print required policy and send verification to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)1
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above due to facility not having a qualified Administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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2
3
4
Facility is in the process of finding a qualified Administrator, statement will be sent to the Dept by POC due date regarding a new Administrator.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to facility not having completed staff training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
1
2
3
4
Facility will write a statement regarding procedure put into place to have training completed. Statement will be sent to the Dept by POC due date.
Type B
Section Cited
CCR
87613(a)(2)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above due to not providing Hospice care plan training and training on oxygen needs to be complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
1
2
3
4
Facility will meet with hospice nurse to have training completed. Verification will be provided to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87463(h)
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to all 6 residents not having either current or completed physician reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
1
2
3
4
Facility will have physician reports completed and verification will be sent to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 04/29/2026 04:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 04/13/2026 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COTTAGE INC, THE
FACILITY NUMBER: 547202420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to facility not providing verification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
1
2
3
4
Facility will implement drills and keep log on file. Statement will be sent to the Dept by POC due date.
Type B
Section Cited
CCR
87212(b)(1)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above due to facility not having a disaster plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Facility will complete disaster forms and provide verification to the Dept by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
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