079200565-11-12-2024-15-AS-CFOR-DAXS5B-20241112123404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200565
Report Date: 11/12/2024
Date Signed: 11/12/2024 12:34:15 PM

Document Has Been Signed on 11/12/2024 12:34 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	COZY FAMILY CARE		FACILITY NUMBER:	079200565
ADMINISTRATOR/ DIRECTOR:	JI, RUI		FACILITY TYPE:	740
ADDRESS:	2135 LUPINE ROAD		TELEPHONE:	(510) 327-4408
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	11/12/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:12 AM
MET WITH:	MARILYN PANTONIAL, ADMINISTRATOR		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/12/24 at 9:400 a.m., Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Pre-Licensing visit due to change of ownership. LPA met with Administrator, Marilyn Pantonial (ADM of new Change of Ownership, ADM Rui Ji unavailable) and explained the purpose of the visit. During the Pre-Licensing visit LPA toured the facility and observed the following deficiencies. · Lighter, scissors in an unlocked drawer, and scissors in the dishwasher. · Facility dose not have enough food. Purchase food non-perishable and perishable. · Staff living in the garage storage room. · missing screen on the kitchen window. · unlocked medication in garage storage/bedroom. unlocked Round-up weed killer in the backyard. continue on LIC 809C

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COZY FAMILY CARE	FACILITY NUMBER: 079200565
	VISIT DATE: 11/12/2024

NARRATIVE

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continue from LIC 809

fruit picker in the back yard.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $500.00 civil penalty will be assessed on today's date for staff living in the garage storage room.*

Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/12/2024 12:34 PM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COZY FAMILY CARE	FACILITY NUMBER: 079200565
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed not to allow staff to sleep in the garage storage. Facility will read understand regulation conduct in-service with staff submit attendees names. Facility will also submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date. civil penalty assessed

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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/12/2024 12:34 PM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COZY FAMILY CARE	FACILITY NUMBER: 079200565
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87705 Care of person with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/13/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove lighter from unlocked drawer and scissors from the dishwasher, lock Round-up and fruit picker and make them inaccessible to residents. Administrator will make correction and submit photos of correction by POC date.

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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC809 (FAS) - (06/04)

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