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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850191
Report Date: 02/12/2023
Date Signed: 02/12/2023 11:17:23 AM


Document Has Been Signed on 02/12/2023 11:17 AM - 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 #1FACILITY NUMBER:
195850191
ADMINISTRATOR:LEVENTER, DVORAFACILITY TYPE:
740
ADDRESS:5416 TYRONE AVENUETELEPHONE:
(818) 855-7019
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 5DATE:
02/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dvora Leventer, Administrator TIME COMPLETED:
11:18 AM
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Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. At 9:00 a.m., the LPAs met with staff and explained the reason for the visit. At 9:30 a.m., one of the Administrators arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

At 9:33 a.m., the LPAs, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards. KITCHEN: The LPAs observed the kitchen/dining area. Knives are inaccessible and stored in a kitchen drawer. Kitchen appliances appear to be in an operable condition. At 9:36 a.m., kitchen hot water measured at 105.9-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet in the laundry room/area. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside locked cabinets in the laundry room/area. The laundry units are located near the kitchen inside the laundry room/area. BEDROOMS: The LPAs observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. At 9:49 a.m., hot water measured at 105.4-degree Fahrenheit. COMMON AREA: The LPAs observed common area to be relatively clean and properly furnished. The LPAs observed the fire extinguishers to be fully charged and last serviced on 11/10/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 9:51 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. The LPAs observed cameras in the common area. OUTDOOR SPACE: The LPAs observed the back patio which has a covered outdoor area for resident use. There are two self-latching gates on each side of the house designated for emergency exits. INFECTION CONTROL: During today’s visit, the LPAs spoke with staff regarding the facility’s infection control practices. The LPAs observed 30 days of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate. No deficiencies were observed at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
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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