195850191-2-10-2024-29-AS-EPEI-D2BSVZ-20240210131333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850191
Report Date: 02/10/2024
Date Signed: 02/10/2024 01:14:41 PM

Document Has Been Signed on 02/10/2024 01:14 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 #1		FACILITY NUMBER:	195850191
ADMINISTRATOR:	LEE,ANNA B DELROSARIO		FACILITY TYPE:	740
ADDRESS:	5416 TYRONE AVENUE		TELEPHONE:	(818) 855-7019
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	02/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Anna Bernice D Lee, Administrator		TIME COMPLETED:	01:20 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 9:50 a.m., the LPAs met with staff and explained the reason for the visit. During the time of the visit, Administrators, Anna Bernice D Lee and Claudette Marasigan arrived at the facility. Entrance interview. At 10:27 a.m., LPA Peraldi, 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 seven (7) bedrooms, six (6) for resident use and one (1) for staff use and five (5) bathrooms. Additionally, the property is connected to an Accessory Dwelling Unit (ADU). Residents do not have access to the ADU. 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. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at 10:34 a.m., the hot water temperature was measured in all bathrooms and were found in compliance between 105.3 and 109.7-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 and inaccessible at the time of the visit. 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 12:05 p.m., hot water measured at 111.6-degree Fahrenheit. 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: 02/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024

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 SHERMAN OAKS #1	FACILITY NUMBER: 195850191
	VISIT DATE: 02/10/2024

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Medications are located in a locked cabinet in the laundry room/area. A first aid kit is located near the kitchen. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside locked cabinets in the laundry room/area. Laundry units are located next to the kitchen in the laundry room/area.

OUTDOOR SPACE: At 10:38 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. There are two gates on each side of the house designated for an emergency exits. The property is gated. 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 10:45 a.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. The 10:47 a.m., the LPAs observed the fire door in the hallway leading to the resident bedrooms not activating during fire alarm. At 12:40 p.m., the LPA’s observed the fire door working properly. LPAs observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways.

RECORD REVIEWS: Between 10:05 a.m. and 11:10 a.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. Copy of valid liability insurance and Facility Emergency Plan was provided to the LPAs during the visit.

Starting at 10:56 a.m., the LPA conducted interviews with two (2) out of five (5) residents and one (1) staff.

Starting at 11:19 a.m., LPA Peraldi conducted a review of medication and medication documentation with Administrator for five (5) residents and observed that all medications were properly documented.

Exit interview conducted. No deficiencies observed at this time. 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: 02/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024

LIC809 (FAS) - (06/04)

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