195850196-2-11-2024-29-AS-EPEI-D2CU66-20240211141748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850196
Report Date: 02/11/2024
Date Signed: 02/11/2024 02:18:15 PM

Document Has Been Signed on 02/11/2024 02:18 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 #3		FACILITY NUMBER:	195850196
ADMINISTRATOR:	QUINTERO, ELEANOR		FACILITY TYPE:	740
ADDRESS:	5805 HILLVIEW PARK AVE		TELEPHONE:	(818) 855-7029
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	02/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Eleanor Jimenez, Administrator		TIME COMPLETED:	02:30 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 12:15 p.m., the LPAs met Administrators, Anna Bernice D Lee, Claudette Marasigan, Eleanor Jimenez and Maurice Lau explained the reason for the visit. At 12:20 p.m., LPA Urena, 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. The property has an attached garage and remains inaccessible to residents. The laundry units are located inside the garage. 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 12:20 p.m., the hot water temperature was measured in all bathrooms and were found in compliance between 105.0 and 120.0-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 12:30 p.m., hot water measured at 1180-degree Fahrenheit. Medications are located in a locked cabinet in the laundry room/area. A first aid kit is located near the kitchen. 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: 02/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2024

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 #3	FACILITY NUMBER: 195850196
	VISIT DATE: 02/11/2024

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OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for resident use. There are emergency exits throughout the facility. 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 12:51 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. Cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside a closet near the front entrance. Medications are located in a locked closet near the dining area.

RECORD REVIEWS: Starting at 12:40 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.

During the time of the visit, the LPAs conducted interviews with one (1) out of five (5) residents.

Starting at 1:05 p.m., LPA Urena conducted a review of medication and medication documentation with Administrator for three (3) 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: 02/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2024

LIC809 (FAS) - (06/04)

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