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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605964
Report Date: 08/04/2023
Date Signed: 08/05/2023 01:25:19 PM


Document Has Been Signed on 08/05/2023 01:25 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:COTTAGE, THEFACILITY NUMBER:
197605964
ADMINISTRATOR:CHRIS GUTIERREZFACILITY TYPE:
740
ADDRESS:1258 N. SIERRA BONITA AVENUETELEPHONE:
(626) 794-9585
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Staff #1TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/04/2023 at 1:05 pm. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for six (6) bedridden residents. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster (LIC 9020)

LPA OBSERVATIONS: Tour began at 1:11 pm and was led by S1. The facility is a single-story building located in a residential area with three (3) resident bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to three (3) out of three (3) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to three (3) out of three (3) residents in care. Kitchen sink water temperature was measured at 135.8 degrees F. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed fully charged fire extinguisher in this area.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 3: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed required auditory devices on exits. Auditory device in resident room# 2 was switched off, According to S1 resident was napping and the sound of the alarm ringing was disturbing the resident, so it was temporarily switched off.

SEE 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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Document Has Been Signed on 08/05/2023 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: COTTAGE, THE
FACILITY NUMBER: 197605964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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Licensee will lower temperature on water heater. Licensee will develop a water log and measure water in resident bathroom# 1 and 2. Licensee will provide first water temperature reading by 8/5/23 via email. Licensee will log water readings every 12 hours for the next 7 calendar days and email log to LPA Ramirez by 8/12/23.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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Licensee will place sign above kitchen sink that warns water temperature my go above 125 degrees F.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/05/2023 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: COTTAGE, THE
FACILITY NUMBER: 197605964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will provide annual training as mention above. Licensee will send via email to LPA Ramirez proof of staff attendace sheet by 8/18/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COTTAGE, THE
FACILITY NUMBER: 197605964
VISIT DATE: 08/04/2023
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Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 136.2 degrees F which not within the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 140.1 degrees F which is not within the required 105 – 120 degrees F.

Centrally Stored Medications: LPA observed cabinet located in hallway to locked and inaccessible to residents in care. Only one (1) resident medication was reviewed.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Emergency Drills: Proof of last documented fire drill was conducted 7/20/20/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan.

Staff Personnel Files: Staff files are maintained at facility. Four (4) staff files were reviewed. LPA Ramirez did not see annual required training for staff that have direct contact with residents.

Resident Files: Three (3) resident files were reviewed. Admissions agreements, Health Screening, and resident personal rights were observed in files.

Liability Insurance & Infection Control Plan: Licensee will send Liability Insurance and Infection Control Plan by 8/11/23.

Deficiencies are being cited during visit. Exit interview was conducted S1 and a copy of this report, 809-D, and appeals rights were provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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