197607071-7-14-2026-28-AS-BGOZ-DVYRY4-20260714132539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607071
Report Date: 07/14/2026
Date Signed: 07/14/2026 01:25:55 PM

Document Has Been Signed on 07/14/2026 01:25 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CHLOIE'S COTTAGE		FACILITY NUMBER:	197607071
ADMINISTRATOR/ DIRECTOR:	LINDA RENARD		FACILITY TYPE:	740
ADDRESS:	747 N. BELLEVIEW AVENUE		TELEPHONE:	(909) 599-3193
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY: 6		CENSUS: 4	DATE:	07/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:24 AM
MET WITH:	Administrator Shorok Kharwish		TIME VISIT/ INSPECTION COMPLETED:	01:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection. LPA was greeted by staff and the purpose of the visit was explained. Administrator Shorok Kharwish arrived shortly after.

The facility is licensed to serve six (6) elderly residents age 60 and above. All residents may be non-ambulatory. The facility is approved for a maximum of three (3) residents on hospice. The facility is a single-story home located in a residential area of San Dimas. The home consists of a kitchen, dining area, living room, (3) resident bedrooms, (2) bathrooms, an office space, staff room, laundry/storage space, and a backyard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Doors, exits, hallways, and passageways were clear and free of obstruction. The front yard and back yards were observed to be clean and free of debris. There is an outdoor shaded seating area in a covered patio with sufficient seating for clients. No pools or bodies of water were observed in or around the home.

Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. Carbon monoxide detector was observed by the front entry, tested and operational. Smoke detectors are located throughout the facility.

continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 07/14/2026 01:25 PM - It Cannot Be Edited

Created By: Blanca Gonzalez On 07/14/2026 at 12:49 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE	FACILITY NUMBER: 197607071
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff did not have a health screening with TB testing available for LPA to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit proof of health screening and TB clearance for S3.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE	FACILITY NUMBER: 197607071
	VISIT DATE: 07/14/2026

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LPA inspected three (3) resident rooms. All residents’ bedrooms contained required furniture and linens all in good repair. Water temperatures in all grooming and bathing areas were measured to be 113.7 °F and 109°F, which is within the 105° – 120° F requirement. LPA observed grab bars near toilets and inside showers. A fire extinguisher was observed. Auditory devices on doors were observed to be in working order. Dining area was clean with sufficient seating. Living room was observed clean and free of obstructions with sufficient seating. LPA observed a variety of food supplies, facility has at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the storage area Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Kitchen was kept clean and free of litter, rodents, vermin and insects.

LPA reviewed three (3) staff files. Files contained background clearance, personnel record, and training for each staff. 1 of 3 staff records reviewed did not contain a health screening with TB clearance. Deficiency cited.

Centrally stored medications were observed locked in a kitchen cabinet.

LPAs reviewed four (4) residents files and each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal.

The facility has a current emergency disaster plan LIC 610E(3/19) last reviewed on 07/05/26. Emergency drills are conducted quarterly, last emergency drill was conducted on 07/01/26. Fire extinguisher located in the kitchen, last serviced 06/2026.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the LIC 809D.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided to Administrator Shorok Kharwish.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC809 (FAS) - (06/04)

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