195850185-2-17-2022-29-AS-EPEI-CBQRMY-20220217120931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850185
Report Date: 02/17/2022
Date Signed: 02/17/2022 12:10:31 PM

Document Has Been Signed on 02/17/2022 12:10 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 VALLEY GLEN #4		FACILITY NUMBER:	195850185
ADMINISTRATOR:	QUINTERO, ELEANOR		FACILITY TYPE:	740
ADDRESS:	6245 MATILIJA AVE		TELEPHONE:	(818) 479-3700
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	02/17/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Eleanor Quintero, Administrator		TIME COMPLETED:	12:15 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	At 10:11 a.m., Licensing Program Analyst (LPA), Emily Peraldi, conducted a pre-licensing visit to this property with applicant representative Eleanor Quintero and Dvora Leventer. This is a change of ownership application from The Colony Valley Glen #4 (#195850101) to Cottages at the Colony of Valley Glen #4 (#195850185). The current census is 5 residents. On 09/09/2021, the applicant obtained fire clearance for a total capacity of six (6) bedridden residents. Between 10:42 a.m.- 11:40 a.m. LPA, along with applicants toured the facility. At 10:51 a.m., LPA toured the kitchen area. The facility has a sufficient supply of perishable and non-perishable food. Kitchen knives are stored in a locked cabinet. Appliances and all equipment appear to be clean and in good repair. The kitchen has a sufficient supply of plates, cups, cook ware and utensils. The freezer and refrigerator are at proper temperature range. At 11:39 a.m. hot water measured at 106.3 degrees Fahrenheit. At 10:46 a.m., LPA observed the fire extinguisher to be fully charged and last serviced on 01/10/2022. At 10:57 a.m., fire alarms and carbon monoxide detectors were tested and were functioning properly. There is a total of seven (7) bedrooms, six (6) single occupancy bedrooms for resident use and one (1) staff room. Each bedroom is equipped with clean mattresses, pillows, bedding, a dresser and closet space. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. There is a total of four (4) bathrooms. Bathrooms have sufficient paper products and soap. At 11:40 a.m. bathroom hot water measured to 106.9 degree- Fahrenheit. There are nightlights present in the hallways. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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 2

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 VALLEY GLEN #4	FACILITY NUMBER: 195850185
	VISIT DATE: 02/17/2022

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

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Facility has a working telephone for resident use. Facility has activity supplies such as board games. There are flashlights present throughout the facility.

Medications and first aid kits are in a locked medication cabinet located near the kitchen. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a locked hallway cabinet.

The facility has a central entry point for universal screening. Alcohol-based hand sanitizer is available upon entry. Signs are posted throughout the facility to promote handwashing, and cough/sneeze etiquette. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE).

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Client Personal Rights, and Facility Theft and Loss Program.

The garage is locked and attached to the house and laundry units are located inside the garage. The office is next to the garage and kept locked. The facility records are in the locked office. At 10:43 a.m., LPA Peraldi observed extra supplies of cleaning solutions and paper products in both the office and garage. There is adequate supply of emergency water, along with emergency nonperishable food. There are no firearms/ammunition stored on the property. The exterior passageways were clean and clear of any obstructions. There are no bodies of water on the premises at the time of the visit.

At 10:46 a.m. the LPA observed the back patio, which has a covered outdoor area for resident use. There is a latch on the side gate for the emergency exit. Physical plant is consistent with the submitted facility sketch/floor plan.

At 10:30 a.m. LPA conducted the pre-licensing inspection tool. On 12/21/2021 at 3:30 p.m. Comp III was conducted.
No corrections are needed at this time. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of the report will be emailed.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2