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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801589
Report Date: 01/13/2025
Date Signed: 01/13/2025 06:19:16 PM

Document Has Been Signed on 01/13/2025 06:19 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAMILYCARE COTTAGE IIFACILITY NUMBER:
565801589
ADMINISTRATOR/
DIRECTOR:		DEBRA BRYANTFACILITY TYPE:
740
ADDRESS:389 RAMBLE RIDGE DR.TELEPHONE:
(805) 492-1200
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
01/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Debra Bryant-AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
NARRATIVE
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On 1/13/2025, Licensing Program Analyst (LPA) Esther Cortez conducted a case management-deficiencies visit in conjunction with the complaint investigation conducted today for a complaint received on 1/10/2024. The purpose of this Case Management is to address the deficiency observed during the course of the complaint investigation. LPA discuss todays observation to Debra Bryant, licensee who came about at 4:00 p.m. The facility was under a red flag warning during today's visit.

The following was observed during today's visit while conducting a file audit

- The staff were not able to provide the destruction records for Resident 1's (R1's) Norco medication that was discontinued on 12/11/2023.


Deficiency issued during this visit today. Exit interview conducted and report issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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Document Has Been Signed on 01/13/2025 06:19 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/13/2025 at 05:04 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87465(i)

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87465(i) Prescription medications which are not taken with the resident upon termination of services,......shall be destroyed in the facility ... to be retained for at least three years, which lists the following:...This requirement is not met as evidenced by:
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Administrator agress that by 09/17/24 they will submit a statement of understanding that they reviewed the regulation and will document when medications are centrally destroyed.
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Based on file review and interviews, the licensee did not comply with the section cited above as they did not have a destruction record for R1's Norco which poses a potential health and safety risk to residents in care.
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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