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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608221
Report Date: 10/19/2021
Date Signed: 10/19/2021 02:16:16 PM

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 COTTAGE IIFACILITY NUMBER:
197608221
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:305 E. BASELINE ROADTELEPHONE:
(909) 592-4488
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 5DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Linda RenardTIME COMPLETED:
02:30 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, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All 4 resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. There is a carbon monoxide in the hallway. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 110.1 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was sufficient perishable food in the kitchen and garage refrigerators. There were a variety of foods including meats, vegetables, and fruit. There was also sufficient non-perishable food. The common areas including the living room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area.

LPA reviewed 5 resident files. Files were complete and included appraisals, physician's reports, medical consent, personal inventory forms. LPA also reviewed 2 staff files to confirm health screenings, fingerprint clearances and training. LPA reviewed residents' medications. Medications are documented properly and given as prescribed.

There was a technical advisory given to the facility for failure to assess LPA at the point of entry. This is a requirement per COVID-19 procedures. There were no deficiencies documented. Exit interview held and a copy of the report and technical advisory were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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