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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850074
Report Date: 04/27/2021
Date Signed: 04/27/2021 04:33:22 PM

Document Has Been Signed on 04/27/2021 04:33 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:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:KATAPODY, GEORGIAFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 5DATE:
04/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Cinthia Meza TIME COMPLETED:
03:50 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210426114434 investigation visit conducted on 4/27/21. Staff Cinthia Meza is authorized to review and sign reports.

During facility tour on 4/27/21 starting at 9:48 am with staff Judith Gonzalez LPA observed Lysol disinfectant spray, rubbing alcohol and resident #1 (R1)'s atorvastatin calcium tablets in an unlocked office accessible to residents. At 9:59 am LPA observed febreeze air freshener in an unlocked staff room accessible to residents. At 10:12 am LPA observed rat bait pellets in a kitchen cabinet accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports and appeal rights were reviewed with staff Meza and a copy was emailed to Licensee/Representative.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2021
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 04/27/2021 04:33 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/27/2021 at 02:59 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: COTTAGE INN
FACILITY NUMBER: 565850074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2021
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care Services. (h)(2) The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible.

This requirement is not met as evidenced by:
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Staff placed medications in a locked medication cabinet during facility visit. Staff stated that they will provide documentation scheduled medication training for staff.
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Based on LPA's observations, the licensee did not comply with the section cited above as resident medications were not kept in a safe locked place which posed an immediate health risk to persons in care.
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Type A
04/28/2021
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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:
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Staff placed items in an inaccessible location during facility visit. Stff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2).
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Based on LPA's observations, the licensee did not comply with the section cited above as toxic substances were observed throughout the facility accessible to residents which posed an immediate health risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2021


LIC809 (FAS) - (06/04)
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