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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606347
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:42:05 PM

Document Has Been Signed on 09/05/2024 03:42 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COGSWELL GARDEN HOMEFACILITY NUMBER:
197606347
ADMINISTRATOR/
DIRECTOR:
LILIAN C. SALMORINFACILITY TYPE:
740
ADDRESS:5405 N. COGSWELL ROADTELEPHONE:
(626) 444-3523
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 15CENSUS: 6DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Staff Arnie CastilloTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Arnie Castillo and explained the reason for the visit.
Shortly thereafter Administrator Lilian Salmorin arrived.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Staff Arnie Castillo today 09/05/2024 at 11:50 AM and the following was observed:
Facility contains 8 Resident Bedrooms and 4 Resident Bathrooms, dining room, living room, TV room, and laundry room.
Required Annual Inspection included Infection Control, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Rights- Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/ Incident Reports, Disaster preparedness, and Residents with Special Health Needs.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Carbon monoxide detector was observed in the facility.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed for 3 residents and was given per physician's directions. 4 Client Files and 5 Staff Files were reviewed.
Interviews were conducted with 3 Staff and 3 residents.
No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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