195850182-3-9-2024-29-AS-MARO-D383PC-20240309172520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850182
Report Date: 03/09/2024
Date Signed: 03/09/2024 05:26:02 PM

Document Has Been Signed on 03/09/2024 05:26 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:	COTTAGES AT THE COLONY OF SHERMAN OAKS #5		FACILITY NUMBER:	195850182
ADMINISTRATOR:	LEE, ANNA B DELROSARIO		FACILITY TYPE:	740
ADDRESS:	5436 TYRONE AVENUE		TELEPHONE:	(818) 855-7022
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:02 PM
MET WITH:	Anna B Del Rosario Lee		TIME COMPLETED:	05:30 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 Analysts (LPAs) Martha Arroyo and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 3:02 PM, LPAs met with the Administrator, Anna Bernice D Lee and explained the reason for the visit. Entrance interview. At 3:04PM the LPA along with the Administrator, 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. The following was noted: The facility is a single-story residential home with nine (9) bedrooms, six (6) for resident use, five (5) bathrooms, and three (3) staff rooms, two (2) of which are inside the Attached Accessory Dwelling Unit (ADU). BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. LPA observed a hallway closet with extra towels and linens for resident use. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at 3:11PM, the hot water temperature was measured in four (4) resident bathrooms, and they measured between 105.3- and 113.5-degrees Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024

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 4

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: COTTAGES AT THE COLONY OF SHERMAN OAKS #5	FACILITY NUMBER: 195850182
	VISIT DATE: 03/09/2024

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
26
27
28
29
30
31
32

Continued from LIC 809...

KITCHEN: The LPAs observed the kitchen and dining area. Knives are stored in a locked drawer inaccessible to residents in care. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food labels were observed for expiration dates. At 3:10PM, the kitchen faucet was measured at 108.6 degrees Fahrenheit. A first aid kit is located near the kitchen.

OUTDOOR SPACE: At 3:04PM, the LPA observed the back patio which has a covered outdoor area with a table and chairs for resident use. There are two gates on each side of the house designated for an emergency exits. The property is gated. Passageways were free and clear from obstruction. There are no bodies of water on the premises. Laundry units and laundry detergents are located in the ADU which are kept inaccessible to the residents.

COMMON AREAS: The LPAs observed common areas to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and last serviced on 10/12/2023. At 3:20PM, fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices and were operational at the time of the visit. Facility telephone was observed during the time of the visit. LPAs observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside a locked bathroom closet.

RECORD REVIEWS: Starting at 3:05PM, the LPAs conducted a file review for all residents and staff
regularly scheduled and observed the following: Staff have current first aid and training documentation
showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: COTTAGES AT THE COLONY OF SHERMAN OAKS #5	FACILITY NUMBER: 195850182
	VISIT DATE: 03/09/2024

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
26
27
28
29
30
31
32

Continued from LIC 809C...

At 3:41PM, records review of R1’s physician’s report, dated 01/31/2024, lists R1 having no capacity for self-care which is a prohibited health condition. At 4:35pm, the Administrator printed updated physician’s report, dated 02/08/2024, which lists R1 is able to feed themselves.

Staff files were complete. The Administrator’s certificate is active and expires on 01/11/2025. The LPAs requested a copy of valid liability insurance and Facility Emergency Plan and Infection
Control Plan. The last emergency disaster drill took place on 03/01/2024.

During the time of the visit, the LPAs conducted interviews with one (1) resident.

At approximately 4:08PM, the LPAs conducted a review of medication and medication documentation with staff for five (5) residents. Medications are centrally stored and locked in a closet by the main entrance hallway. At 4:16PM, medication review of R2’s medication revealed that medication Mirtazapine Tablets, USP, 30 mg is missing the prescription label as the medication box which had the prescription label was discarded; therefore, LPAs were unable to determine if medication is being administered as prescribed by physician/pharmacy. Staff state they will make sure they do not discard medication box with prescription label in the future.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/09/2024 05:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES AT THE COLONY OF SHERMAN OAKS #5	FACILITY NUMBER: 195850182
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above as R2's medication for Mirtazapine Tablets, USP, 30 mg did not have a prescription label as the medication box was discarded, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2024
	Plan of Correction
1 2 3 4	The Licensee will have an outside vendor conduct training on medication and submit proof to CCL before poc due 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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4