195850185-3-10-2024-29-AS-EPEI-D38RTQ-20240310131844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850185
Report Date: 03/10/2024
Date Signed: 03/10/2024 01:19:07 PM

Document Has Been Signed on 03/10/2024 01:19 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 VALLEY GLEN #4		FACILITY NUMBER:	195850185
ADMINISTRATOR:	QUINTERO, ELEANOR		FACILITY TYPE:	740
ADDRESS:	6245 MATILIJA AVE		TELEPHONE:	(818) 855-7035
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 4	DATE:	03/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Eleanor Jimenez, Anna Bernice D Lee		TIME COMPLETED:	01:30 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) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 11:55 a.m., the LPAs met with the Administrators, Anna Bernice D Lee and Eleanor Jimenez explained the reason for the visit. At 11:56 a.m., the LPA along with staff, 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 seven (7) bedrooms, six (6) for resident use and one (1) for staff use and four (4) bathrooms. OUTDOOR SPACE: At 11:56 a.m., the LPA observed the back patio. There are no bodies of water on the premises at the time of the visit. Laundry units, cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside the locked garage. There is one (1) gate on the side of the house designated for an emergency exits. Passageways were free and clear from obstruction. KITCHEN: The LPAs observed the kitchen and dining area. Knives are stored in a locked safety box. 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 9:48 a.m., the kitchen faucet was measured and tested withing required range. Medications are located in a locked storage closet inside the kitchen. A first aid kit is located inside the kitchen. 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. 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: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

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 VALLEY GLEN #4	FACILITY NUMBER: 195850185
	VISIT DATE: 03/10/2024

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RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at 12:25 p.m., the hot water temperature for restrooms were tested and measured within the required range. Sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing.

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 12:21 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.

RECORD REVIEWS: Starting at 12:02 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 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 12:36 p.m., the LPAs conducted a review of medication and medication documentation with staff for four (4) 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: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

LIC809 (FAS) - (06/04)

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