195850191-3-24-2025-29-AS-QHUH-DF3R2D-20250324123810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850191
Report Date: 03/24/2025
Date Signed: 03/24/2025 12:39:45 PM

Document Has Been Signed on 03/24/2025 12:39 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/ DIRECTOR:	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: 6	DATE:	03/24/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:58 AM
MET WITH:	Anna Lee - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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Licensing Program Analysts (LPAs) Quoc Huynh and Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 9:58AM. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Anna Lee arrived shortly after. Entrance interview conducted.

Beginning at 10:15AM, the LPAs and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS/RESTROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms and one (1) staff room. There are five (5) total bathrooms in the facility; two (2) is designated as a shared common restroom and three (3) private bathrooms. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper towels. Hot water was tested between 10:15AM-10:40AM and tested between 112.3 degrees F and 113.4 degrees F, which was in the required range.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Smoke and carbon monoxide detectors as well as fire doors were tested at 11:45AM and were operational at the time of the visit. The fire extinguisher was fully charged and serviced on 10/08/2024. The LPAs observed required postings on the entry way hallway.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

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: 03/24/2025

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KITCHEN: The LPAs observed the facility kitchen. Knives are stored inaccessible. Cleaning supplies are stored inaccessible in the laundry room. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPAs noted the kitchen sink and surrounding grout on the countertop had mold build up. Administrator began correction during the visit.

OUTDOOR AREA: The backyard has a covered patio area equipped with furniture for resident use. There are two (2) side gates for emergency exit use and are single latched with an alarm. No bodies of water noted and exits are free of obstructions. The LPAs observed a shed behind the facility which stored decorations and emergency water.

RECORDS: Records review began at 10:36AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 11:47AM; medications are centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPAs reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 03/03/2025.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

LIC809 (FAS) - (06/04)

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