<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850149
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:42:05 PM

Document Has Been Signed on 08/29/2023 03:42 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, 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:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Vardan Adzemian, LicenseeTIME COMPLETED:
03:50 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
Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 2:30 p.m., the LPA met with the Licensee and explained the reason for the visit.

Currently the facility has zero (0) clients and is waiting to be vendored through North Los Angeles County Regional Center. At 2:53 p.m., the LPA, along with the Licensee 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.

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 2:55 p.m., hot water measured at 105.3-degree Fahrenheit. Medications and first aid kits will be located in a locked cabinet near the kitchen. BEDROOMS: The LPA observed client bedrooms, which have sufficient lighting. Currently the rooms are 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. At 2:57 p.m., hot water measured at 106.5-degree Fahrenheit. 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 06/13/2023. At 2:57 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. OUTDOOR SPACE: 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. The LPA observed cameras at the exterior perimeter of the facility. 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.

No deficiencies were observed at this time. Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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 1