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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850149
Report Date: 08/30/2022
Date Signed: 08/30/2022 11:48:40 AM

Document Has Been Signed on 08/30/2022 11:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COZY ADULT CARE INC.FACILITY NUMBER:
195850149
ADMINISTRATOR:PUNO, MICHELLEFACILITY TYPE:
735
ADDRESS:13554 CANTARA ST.TELEPHONE:
(323) 348-8522
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 4CENSUS: 0DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Anabel Ayvazian TIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:30 a.m., the LPA met with staff, Anabel Ayvazian and explained the reason for the visit. The Licensee was not available at the time of the visit and authorized staff, Anabel Ayvazian to sign the report.
This annual had a specific emphasis on infection control practices and procedures. Currently the facility has zero (0) clients and is waiting to be vendored through North Los Angeles County Regional Center.

At 11:00 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed client bedrooms, which have sufficient lighting. The facility has Bedroom three (3) as a model room which is properly furnished with a mattress, clean linens, a dresser and a closet space. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:04 a.m., hot water measured at 105.7-degree Fahrenheit.

OUTDOOR SPACE: At 11:05 a.m., the LPA observed the back patio which has a covered outdoor area for client use. There is a gate on the side of the house designated for an emergency exit.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and purchased on 08/29/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 11:10 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COZY ADULT CARE INC.
FACILITY NUMBER: 195850149
VISIT DATE: 08/30/2022
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KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:09 a.m., hot water measured at 115.1-degree Fahrenheit. Medications and first aid kits will be located in a locked cabinet near the kitchen.

GARAGE: The garage is attached to the house. The garage contains additional supplies such as water, paper products and Personal Protection Equipment (PPE). The laundry units are located in the hallway near the garage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility will have a central entry point for symptom screening, temperature checks, and a sanitation station. The LPA observed a 30-day supply of PPE and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

At 10:50 a.m., the LPA conducted Infection Control mitigation module with the staff.

No deficiencies were observed at this time. Exit interview conducted and report issued, and a copy of the report will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
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