565801978-7-7-2022-29-AS-MARO-CG4QF7-20220707120728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801978
Report Date: 07/07/2022
Date Signed: 07/07/2022 12:08:34 PM

Document Has Been Signed on 07/07/2022 12:08 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 IV		FACILITY NUMBER:	565801978
ADMINISTRATOR:	DEBRA BRYANT		FACILITY TYPE:	740
ADDRESS:	825 CALLE CEDRO		TELEPHONE:	(805) 380-4108
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	07/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Debra Bryant		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required 1-year annual inspection today at 9:35 a.m. The last annual conducted was on 6/06/2019. Upon arriving at the facility, two (2) staff were observed not wearing face masks in the common areas. The LPA was scanned and greeted at the door by staff Josafina. The LPA met with the Administrator and was explained the reason for the visit. Entrance interview conducted.

At 9:45 a.m., the LPA began the physical plant tour with the Administrator of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps in a locked cabinet above the oven locked and inaccessible to residents. Toxins and cleaning supplies were observed locked under the kitchen sink at the time of visit. The LPA observed the Medications cart locked in the kitchen inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels for resident use. Bathrooms were measured for hot water, the first bathroom measured at 105.8 degrees Fahrenheit at 9:50 a.m. and the second bathroom measured at 105.8 degrees Fahrenheit at 9:53 a.m.

…Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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 IV	FACILITY NUMBER: 565801978
	VISIT DATE: 07/07/2022

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…Continued from LIC 809...

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. There is one (1) additional freezer and one (1) refrigerator in the garage with perishable items in good condition. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Facility has a adequate amount of emergency food and emergency water. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed two (2) residents in the living room watching television and another two (2) residents in the dining room doing activities.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA and Administrator discussed staff vaccination requirements. All staff and residents are fully vaccinated and double boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 9099-D)

Exit interview conducted. Appeal Rights discussed. A copy of this report was sent via email to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2022 12:08 PM - It Cannot Be Edited

Created By: Martha Arroyo On 07/07/2022 at 11:29 AM

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 IV	FACILITY NUMBER: 565801978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as two (2) staff were observed not wearing masks/face coverings in common areas, which poses an immediate health, safety, and personal rights risk to persons in care.
	POC Due Date: 07/07/2022
	Plan of Correction
1 2 3 4	Staff was asked to wear face masks during visit and Administrator will hold a training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 7/07/2022.

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:

Desaree Perera

LICENSING EVALUATOR NAME:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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