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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607071
Report Date: 08/06/2022
Date Signed: 08/06/2022 01:24:53 PM


Document Has Been Signed on 08/06/2022 01:24 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: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:
08/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Administrator, Linda RenardTIME COMPLETED:
01:40 PM
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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 and records, staff records and observed the food supply. The facility cares for elderly residents and is approved to care for 3 hospice residents. There are currently 3 residents on hospice.

All resident bedrooms were toured. Bedrooms have the required bed, bedframe, linen, dresser, light, and closet space. Resident bathrooms were toured. Bathrooms have the required grab bars and non-skid mats. The hot water was 109.8 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is an additional refrigerator in the garage. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are no cameras inside the facility. There is a screening station with PPEs at the entrance of the facility. Staff document resident and staff temperatures symptoms daily.

Resident files were reviewed to confirm emergency contacts are updated along with physician's reports. Staff files were reviewed to confirm health screenings and infection control training. All files were complete. All residents' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. 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: 08/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2022
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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