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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606347
Report Date: 09/12/2023
Date Signed: 09/12/2023 01:48:14 PM


Document Has Been Signed on 09/12/2023 01:48 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:LILIAN C. SALMORINFACILITY TYPE:
740
ADDRESS:5405 N. COGSWELL ROADTELEPHONE:
(626) 444-3523
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:15CENSUS: 9DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lilian SalmorinTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Caregiver Zenaida Libaton 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 Administrator Lilian Salmorin today 09/12/2023 at 11:20 AM and the following was observed:
Facility contains 8 Client Bedrooms and 4 Client Bathrooms, dining room, living room, TV room, and laundry room.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Training, Client Rights- Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster preparedness, and Emergency Intervention.
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 and was given per physician's directions.
3 Client Files and 3 Staff Files were reviewed.
Interviews were conducted with 3 Staff and 3 client's.
There is currently no activity schedule and no activities being done at the facility.
Deficiency cited on the 809 D.


Exit interview conducted and copy provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/12/2023 01:48 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: COGSWELL GARDEN HOME
FACILITY NUMBER: 197606347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview), the licensee did not comply with the section cited above in 3 out of 3 clients stated there are no activities which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator to submit monthly activity schedule by POC due date.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2