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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134603706
Report Date: 05/20/2021
Date Signed: 05/21/2021 11:16:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:A&A COTTAGE VIEW ASSISTED LIVING,INC.FACILITY NUMBER:
134603706
ADMINISTRATOR:ZADEH, AKBARFACILITY TYPE:
740
ADDRESS:103 S HASKELL DRIVETELEPHONE:
(442) 283-5500
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:14CENSUS: 11DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Vanessa Guzman, Administrator, Licensee Akbar ZadehTIME COMPLETED:
11:41 AM
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Licensing Program Analyst (LPA) Daniel Pena visited the facility to conduct an annual required licensing inspection. LPA was met by Vanessa Guzman, Administrator and Akbar Zadeh, Licensee and was granted entry into the facility after identifying himself and explaining the purpose of the visit.

During today's visit, LPA toured the facility, interacted with residents and staff and verified compliance with infection control practices. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of cleaning products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Ms. Guzman and Mr. Zadeh and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to Licensee Zadeh via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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