195850184-3-9-2024-29-AS-EPEI-D37UUA-20240309145315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850184
Report Date: 03/09/2024
Date Signed: 03/09/2024 02:53:37 PM

Document Has Been Signed on 03/09/2024 02:53 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COTTAGES AT THE COLONY OF SHERMAN OAKS #4		FACILITY NUMBER:	195850184
ADMINISTRATOR:	LEE, ANNA B DELROSARIO		FACILITY TYPE:	740
ADDRESS:	5430 TYRONE AVENUE		TELEPHONE:	(818) 855-7021
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 6	DATE:	03/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Anna Bernice D Lee, Administrator		TIME COMPLETED:	02:55 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) Emily Peraldi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. At 12:30 p.m., the LPAs met with the Administrators, Anna Bernice D Lee and Claudette Marasigan and explained the reason for the visit. Entrance interview. At 12:45 p.m., 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 facility is a single-story residential home with nine (9) bedrooms, six (6) for resident use and three (3) for staff use, two (2) of which are inside the ADU and three (3) bathrooms. The LPAs observed the Accessory Dwelling Unit (ADU) that was previously the garage. The Administrator stated that the ADU will not be for resident use. 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 two (2) 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 12:56 p.m., the hot water temperature was measured in bathrooms, and measured between 108.5 and 110.4 degrees Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. KITCHEN: The LPAs observed the kitchen and 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. Food labels were observed for expiration dates. At 12:49 p.m., the kitchen water temperature was measured at 111.7 degrees Fahrenheit. Medications are located in a locked cabinet adjacent to the kitchen. A first aid kit is located near the kitchen. Continued on LIC-809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES AT THE COLONY OF SHERMAN OAKS #4	FACILITY NUMBER: 195850184
	VISIT DATE: 03/09/2024

NARRATIVE

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OUTDOOR SPACE: At 12:46 p.m., 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.

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 1:03 p.m., 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. Laundry units are located inside the laundry room. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside a locked closet near the laundry area.

RECORD REVIEWS: Starting at 12:35 p.m., 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, consent forms. All files were in order. 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.

At approximately 1:50 p.m., the LPAs conducted a review of medication and medication documentation with staff for six (6) residents. Three (3) out of three (3) residents with PRN medications did not have the PRN authorization form on file. At 2:05 p.m., the Administrator printed out the PRN authorization forms for the three (3) residents.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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)

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