195850196-2-17-2022-29-AS-EPEI-CBQVGF-20220217152527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850196
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:26:02 PM

Document Has Been Signed on 02/17/2022 03:26 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 #3		FACILITY NUMBER:	195850196
ADMINISTRATOR:	QUINTERO, ELEANOR		FACILITY TYPE:	740
ADDRESS:	5805 HILLVIEW PARK AVE		TELEPHONE:	(818) 479-3700
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 6	DATE:	02/17/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Eleanor Quintero, Administrator		TIME COMPLETED:	03:28 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 2:00 p.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 #3 (#195850100) to Cottages at the Colony of Valley Glen #3 (#195850196). The current census is 6 residents. On 09/09/2021, the applicant obtained fire clearance for a total capacity of six (6) bedridden residents. Between 2:23 p.m.- 3:15 p.m. LPA, along with applicants toured the facility. At 2:35 p.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 kitchen drawer. 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 3:20 p.m. hot water measured at 107.0 degrees Fahrenheit. At 2:24 p.m., LPA observed the fire extinguisher to be fully charged and last serviced on 01/10/2022. At 2:38 p.m., fire alarms and carbon monoxide detectors were tested and were functioning properly. There is a total of eight (8) bedrooms, six (6) single occupancy bedrooms for resident use and two (2) 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 six (6) bathrooms. Bathrooms have sufficient paper products and soap. At 2:59 p.m. bathroom hot water measured to 105.3 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)

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES AT THE COLONY OF VALLEY GLEN #3	FACILITY NUMBER: 195850196
	VISIT DATE: 02/17/2022

NARRATIVE

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Continued from LIC 809.

The living areas and dining areas are clean and properly furnished. Near the living area, the facility has a media room for resident use. 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 and puzzles. There are flashlights present throughout the facility.

Medications and first aid kits are in a locked medication storage closet located near the dining area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a locked storage closet near the front door entrance. 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. There is adequate supply of emergency water, along with emergency nonperishable food. There are no firearms/ammunition stored on the property.
At 2:28 p.m. the LPA observed the backyard, which has a shaded 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. 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 2:05 p.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)

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