195850184-2-12-2023-29-AS-MARO-CNYTYM-20230212140859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850184
Report Date: 02/12/2023
Date Signed: 02/12/2023 02:09:42 PM

Document Has Been Signed on 02/12/2023 02:09 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 #4		FACILITY NUMBER:	195850184
ADMINISTRATOR:	LEVENTER, DVORA		FACILITY TYPE:	740
ADDRESS:	5430 TYRONE AVENUE		TELEPHONE:	(818) 855-7021
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 6	DATE:	02/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Dvora Leventer		TIME COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs), Martha Arroyo and Emily Peraldi arrived unannounced to conduct a Required 1-Year Annual with focus on Infection Control. This will be the first Annual conducted at this facility following the pre-licensing visit for change of ownership on 12/22/2021. The LPA’s met with the Administrator, Dvora Leventer and the reason for the visit was explained. Entrance Interview.

The LPAs along with the Administrator began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, staff rooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The LPAs observed three resident bathrooms for hot water temperature; the first bathroom measured 105.8 degrees Fahrenheit at 11:33 am; the second bathroom measured 105.3 degrees Fahrenheit at 11:38 am; and the third bathroom measured 109.4 degrees Fahrenheit at 11:46 am. LPAs observed an adequate amount of perishable and non-perishable food. LPAs observed fire extinguisher was fully charged on 11/10/2022. At 11:43 am, the smoke detectors and carbon monoxide detectors were tested and operable. LPAs observed medications, sharps, and knives in a locked cabinet adjacent to the kitchen. The laundry room and cleaning supplies were observed locked and inaccessible to residents in care. LPAs observed Emergency food and water supply. The living areas and dining areas are clean and properly furnished. LPAs observed cameras throughout the common areas. The facility was maintained at 69 degrees Fahrenheit at the time of visit. LPAs observed outdoor grounds with clear passageways with no obstructions for emergency use. No bodies of water observed at the time of visit.

Report 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: 02/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2023

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: COTTAGES AT THE COLONY OF SHERMAN OAKS #4	FACILITY NUMBER: 195850184
	VISIT DATE: 02/12/2023

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Report Continued from LIC 809 ...

During today's visit, the LPAs spoke with the Administrator regarding the facility's infection control practices. The LPAs observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS Pins. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVlD-19. All staff are fully vaccinated and boosted. The LPAs observed staff wearing face coverings at the time of visit. No identified staffing concerns.

Exit interview conducted. No citations issued. Report was reviewed and issued to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2023

LIC809 (FAS) - (06/04)

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