<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801505
Report Date: 10/23/2024
Date Signed: 11/21/2024 09:52:19 AM

Document Has Been Signed on 11/21/2024 09:52 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAMILYCARE COTTAGE ONEFACILITY NUMBER:
565801505
ADMINISTRATOR/
DIRECTOR:
CHRISSY CORTEZFACILITY TYPE:
740
ADDRESS:820 CALLE CEDROTELEPHONE:
(805) 492-1200
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Marisol FlamencoTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:20AM. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Marisol Flamenco arrived shortly thereafter. Entrance interview conducted.

Beginning at 10:40AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was observed to be fully charged and Administrator stated was recently purchased, around the time of LPA Chochian's last visit. LPA Dulek advised Administrator to retain proof of purchase date. All combination smoke and carbon monoxide detectors were functional during testing.

KITCHEN/GARAGE: The LPA began the inspection in the kitchen/food service area. One knife and one lighter were observed in a small drawer next to the stove, which was unlocked and accessible to residents in care. Items were secured in a locked location upon discovery. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Adjacent to the kitchen is the facility garage. The garage was observed to be locked and contains emergency food and water, extra food, cleaning supplies, and laundry.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Auditory alarms on exit doors were observed to be functioning at this time. The LPA observed required postings throughout the common space.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) designated resident rooms; 4 (four) are private rooms and 1 (one) is a


Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FAMILYCARE COTTAGE ONE
FACILITY NUMBER: 565801505
VISIT DATE: 10/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
shared resident room. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: The facility contains 3 (three) restrooms. 1 (one) full restroom and 1 (one) half bath are located in the hallway and are designated for shared use. 1 (one) restroom is located in a private resident room, however is utilized by another resident, as it contains an accessible shower and the common restroom does not. Resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature initially measured low, however was retested later when the washing machine cycle had completed and measured at 107.4 degrees Fahrenheit.

RECORDS: Records review began at 11:04AM; records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 01:19PM; LPA reviewed medications for 2 (two) residents. Medications are centrally stored and locked in a medication cart in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility has an infection control plan and emergency disaster plan; both of which were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 08/13/2024.

INTERVIEWS: During today's visit, LPA conducted interviews with both staff and residents. No concerns were noted during interviews.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations,


Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil
penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/21/2024 09:52 AM - It Cannot Be Edited


Created By: Kelly Dulek On 10/23/2024 at 01:39 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILYCARE COTTAGE ONE

FACILITY NUMBER: 565801505

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as a knife and a lighter were observed in an unlocked kitchen drawer and accessible to residents with dementia, which poses an immediate safety risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
1
2
3
4
Items were secured in the appropriate locked location during today's visit. Administrator spoke with staff regarding safe storage of hazardous items. POC cleared.
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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/21/2024 09:52 AM - It Cannot Be Edited


Created By: Kelly Dulek On 10/23/2024 at 01:39 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILYCARE COTTAGE ONE

FACILITY NUMBER: 565801505

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as the facility's exit gate was observed to not contain a latch and unable to close, which poses a potential safety risk to residents in care.
POC Due Date: 11/06/2024
Plan of Correction
1
2
3
4
Administrator took photographs and contacted the facility handyman during today's visit. All repairs will be completed and proof sent to CCL by POC due date.
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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4