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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850074
Report Date: 10/28/2025
Date Signed: 10/28/2025 01:37:51 PM

Document Has Been Signed on 10/28/2025 01:37 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:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR/
DIRECTOR:		DANIA FAYYADFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 4DATE:
10/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:22 AM
MET WITH:Judith GonzalezTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management - Deficiencies visit at the facility at 10:22 AM. LPA met with facility staff who contacted the Administrator Dania Fayyad via telephone call. The Administrator was unavailable to come to the facility at the time of the visit. LPA explained the reason for the visit to Judith Gonzalez (S1) and entrance interview was conducted.

During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, two (2) residents, and two (2) witnesses, and collected copies of pertinent documentation between 10:22 AM and 12:56 PM.


Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074
VISIT DATE: 10/28/2025
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On 01/17/2025 the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint against the facility. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laura Garcia. During the course of the investigation IB concluded the following. On 09/24/2024 at approximately 0800 hours, resident #1 (R1) was found by their commode on the floor. Staff immediately evaluated R1 for any injuries, pain or swelling. Staff did not observe any injuries, swelling or redness. According to staff, R1 was reportedly observed ambulating throughout the facility without pain. However, staff #1 (S1) indicated that when they initially found R1 by their commode, R1 told S1 that they bumped their head but expressed no pain. Upon review, it appeared that staff only monitored R1 for pain levels but failed to seek immediate medical attention on 09/24/2024. On 09/26/2024, R1’s responsible party (W1) came to visit R1 and noticed that R1 had pain and took them to get medically evaluated. R1 was noted to have a fracture to the pelvis. Based on the R1’s medical history it is unknown how/ where the fracture was sustained however, staff should have sent R1 to get medically evaluated. Based on the above information and documentation provided, there is sufficient evidence that the facility failed to seek immediate medical attention for R1.

The following deficiency was cited (refer to LIC 809D). The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2025 01:37 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/28/2025 at 10:47 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: COTTAGE INN
FACILITY NUMBER: 565850074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2025
Section Cited
CCR
87465(a)(1)

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87465 Incidental Medical and Dental Care
(a) ...The plan shall... provide for assistance in obtaining such care...
(1) The licensee shall arrange...for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding confirming that they will seek timely medical attention appropriate to the needs and conditions of the clients in care. Administrator agreed to submit the document to CCLD for review no later than POC due date.
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Based on interviews and record review the licensee did not comply with the section cited above as facility staff observed R1 on the floor after falling off of their commode. R1 expressed that they hit their head but staff did not seek medical attention for R1 which posed a potential health risk to clients 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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