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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801589
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:50:21 PM

Document Has Been Signed on 11/16/2022 03:50 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAMILYCARE COTTAGE IIFACILITY NUMBER:
565801589
ADMINISTRATOR:DEBRA BRYANTFACILITY TYPE:
740
ADDRESS:389 RAMBLE RIDGE DR.TELEPHONE:
(805) 492-1200
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Debra Bryant TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) KaSandra Lopez arrived at the facility unannounced to conduct a required annual visit at 12:38 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with the caregiver and advised her of the reason for the inspection. Administrator Debra Bryant arrived shortly after the inspection began.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and purchased within the last year.

KITCHEN: Knives and cleaning supplies are stored in locked cabinets. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are stored in a locked medicine cart in the kitchen.

BEDROOMS: The LPA observed six resident bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility does not have a staff room.

RESTROOMS: There are two common restrooms for resident use which were clean and sanitary and in operating condition with hand soap and paper towels. At 12:58 PM the hot water temperature tested in the common bathroom next to bedroom #3 measured at 127 degrees F.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. Auditory devices observed were functioning. The LPA observed the required postings upon entry. The backyard patio is equipped with furniture for residents' use. In the unlocked garage, the LPA observed cleaning supplies and laundry detergent unsecured and accessible to residents.

Report continued LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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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 II
FACILITY NUMBER: 565801589
VISIT DATE: 11/16/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff are showing symptoms of COVID-19 or testing positive for COVID-19.

The following deficiencies were cited from the CA Code of Regulations. See LIC 809-D. Exit interview conducted and report reviewed with the Administrator. A copy of the report and appeals rights was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2022 03:50 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 11/16/2022 at 02:02 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 II
FACILITY NUMBER: 565801589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the hot water in the bathroom next to bedroom #3 measured at 127 degrees F. which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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The Administrator shall submit a five day water temperature log indicating the hot water temperature is within 105-120 degrees F. The log should be submitted to CCL by 11/23/2022.
Type A
Section Cited
HSC
87705(f)(2)

87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cleaning supplies an detergent were unsecured in an unlocked garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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The items were secured in locked cabinets in the garage. Plan of correction is cleared.
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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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