197607760-7-2-2024-11-AS-DESA-D6SVLA-20240702163136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607760
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:33:42 PM

Document Has Been Signed on 07/02/2024 04:33 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	COUNTRY COTTAGE II		FACILITY NUMBER:	197607760
ADMINISTRATOR:	LOFTON, JANICE		FACILITY TYPE:	740
ADDRESS:	5302 W 119TH ST		TELEPHONE:	(310) 722-7541
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90304
CAPACITY:	3	CENSUS: 3	DATE:	07/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	Janice M Lofton, Administrator		TIME COMPLETED:	05:00 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	On 07/02/24, at 2:00 pm Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full CAREs tool. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA España was met by Janice Lofton, Administrator and the purpose of today’s visit was explained. Residents were present at the time of visit. The facility is licensed for 3 non-ambulatory. LPA España conducted a tour of the facilities physical plant inside and outside to ensure safety for all residents. The resident medications were reviewed for proper storage, documentation, and system implementation. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage of perishable (2 days) and nonperishable (7 days). LPA España toured the key areas in the facility which were 3-bedrooms, 2-bedrooms, focusing on the laundry facilities, kitchen amenities, and a brief note on the roof condition. LIC 809C Continued

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COUNTRY COTTAGE II	FACILITY NUMBER: 197607760
	VISIT DATE: 07/02/2024

NARRATIVE

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Laundry Facility (located in kitchen): Equipped with both washer and dryer. Dedicated laundry area available. Kitchen Features: Fully equipped with appliances. Appliances include dishwasher. Garbage disposal. Microwave. Features a breakfast counter or bar. Exterior: Roof inspection conducted. Shingles observed on the roof. Storage was observed and locked such as toxic cleansers, and general storage. Personal accommodations observed for safety, privacy, and comfort, including grab bars, nonskid mats and/or strips, and required furniture. LPA España measured the hot water temperature to ensure it is maintained within the required range of 105 – 120 F for residents’ comfort and safety. The hot water temperature measured at 109 F. Fire extinguisher fully charged. Fire alarm operable. First aid kit found in compliance. Recent fire drill completed on March 20, 2024, and June 15, 2024. Staff/client records were made available for review during this visit. All files found in compliance. Brenda Chandler Administrator certificate expires 01/06/2025. Janice Lofton Administrator certificate expires 1/20/25. All mandated documents are posted in visible area. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit.

Exit visit. Copy of report signed and given to Janice Lofton Administrator.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

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