197607760-11-6-2023-11-AS-ARID-CXBTHT-20231106134517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607760
Report Date: 11/06/2023
Date Signed: 11/06/2023 01:45:29 PM

Document Has Been Signed on 11/06/2023 01:45 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Brenda Chandler		TIME COMPLETED:	02:00 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 11/06/23, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with staff Karina Thong and explained the purpose of today’s visit. The facility is licensed to operate for (3) developmentally disabled elderly adults. The facility is cleared for 3 non-ambulatory. The consumers are Westside Regional Center residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA and staff toured the physical plant. There were no obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 117. 3F degrees. A comfortable temperature of 73 degrees was maintained in the facility. Later, LPA was joined by Licensee Branda Chandler, and Administrator Lofton Janice. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY COTTAGE II	FACILITY NUMBER: 197607760
	VISIT DATE: 11/06/2023

NARRATIVE

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has two (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. LPA Richard reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. A working landline telephone remains available. An emergency fire drill was conducted on 09/07/23.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas. LPA observed some of the staff members were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to administrator Lofton Janice.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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