<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607071
Report Date: 08/06/2021
Date Signed: 08/06/2021 03:30:35 PM

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:CHLOIE'S COTTAGEFACILITY NUMBER:
197607071
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:747 N. BELLEVIEW AVENUETELEPHONE:
(909) 599-3193
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator, Linda RenardTIME COMPLETED:
03:45 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 Analyst (LPA) Vasallo conducted an annual required visit. LPA met with administrator, Linda Renard and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff and resident files.

All 3 resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 116.2 degrees which is within the required 105 - 120 degrees. Bathrooms have sufficient hygiene products. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The backyard has a shaded area and patio furniture.

All 6 resident files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations. Staff files were reviewed to confirm COVID-19 vaccination or COVID-19 negative test results. Staff present at the facility had fingerprint clearances. Residents' medication were reviewed. Medication are documented and given as prescribed.

Per Title 22 Regulations, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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 1