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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607071
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:57:11 PM


Document Has Been Signed on 08/24/2023 03:57 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: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: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Linda RenardTIME COMPLETED:
04:01 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Staff Maria Blanco and explained the purpose of the visit. Administrator Linda Renard arrived a few minutes after. LPA utilized the care tool for this inspection.

LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Sufficient PPE supplies and has an Infection Control Plan on file.
Physical Plant & Environment Safety: The 1-story facility is good repair. Fire and carbon monoxide detectors are in every room and were operation. Fire extinguisher are located at facility and serviced. The one story facility consist of the following:
Three shared resident Bedrooms and 2 Resident Bathrooms, dining room, living room, TV room, staff room, office and patio/deck area.
Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility does have proof of enough liability insurance covering injury to residents and guest. Water temperature measured 117.1 – 117.3 which is within required range.
Staffing: There appears to be sufficient staffing at the facility. The administrator’s Maria Blanco’s certificate expires 12/202024. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and evidence of on-going training.

(Continued on 809C)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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 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: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 08/24/2023
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(Continued from 809

Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Pre-Admission Agreements, Updated Physicians report, personal rights and other required documentation.
Residents Rights-Information: The Complaint poster and personal rights are posted by the main entrance. Food Service: Facility has 2 days perishable food and 7 days nonperishable food at time of visit.
Incidental and medical services: Medication files were reviewed for all 4 residents and all medication is given as doctor ordered.
Planned Activities: Facility has planned activities and supplies and space for activities.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Resident with Special health needs: Facility does not have any residents with special health needs during the time of visit.

During today’s visit, no deficiencies were observed, 2 technical advisories were provided, exit interview conducted and report provided to Administrator Linda Renard

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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