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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002891
Report Date: 06/25/2024
Date Signed: 06/25/2024 10:38:25 AM


Document Has Been Signed on 06/25/2024 10:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:FOOTHILL COTTAGEFACILITY NUMBER:
045002891
ADMINISTRATOR:ABEJO, KRISTINEFACILITY TYPE:
740
ADDRESS:3064 CEANOTHUS AVENUETELEPHONE:
(530) 809-0418
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:6CENSUS: 3DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Administrator- Kristine AbejoTIME COMPLETED:
11:00 AM
NARRATIVE
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On 06/25/2024, Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with the administrator, Kristine Abejo, and explained the purpose of the visit.

LPA Boyles and House Manager toured facility together to ensure health and safety of residents in care. LPA's observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed each bedroom to have the required furnishings, working lights and windows with screens. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed cleaning supplies under the bathroom sink which are accessible to residents in care.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 105 F. LPA observed one fire extinguisher, fire detectors, and carbon monoxide detectors. LPA observed a complete first aid kit ready for emergency use. LPA observed a complete emergency disaster plan and emergency drills conducted as required. LPA observed medications to be locked and inaccessible to residents.

LPA reviewed a total of three (3) residents' files and two (2) staff files which contained all of the required documentation.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


Several topics were discussed.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/25/2024 10:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in that chemicals were found to be stored under a bathroom sink unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The administrator will provide a training to the staff of the importance of storing chemicals inaccessible to residents. Administrator will inform the LPA when the training is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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