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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608221
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:21:08 PM


Document Has Been Signed on 08/13/2024 03:21 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 IIFACILITY NUMBER:
197608221
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:305 E. BASELINE ROADTELEPHONE:
(909) 592-4488
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Caregiver Maria BlancoTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Annual Required Visit at 11:41 AM. LPA was met by Assistant Administrator Maria Blanco and explained the purpose of the visit. The fire clearance is approved for Six (6) non- ambulatory residents. There is a hospice waiver approved for 3 residents. During today’s visit facility was found to have one (1) bedridden resident without approved fire clearance civil penalties assessed.

The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 2 resident bathrooms, living room, kitchen, dining area, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage was observed to be converted into a bedroom with walls and a closet deficiency cited.

SEE LIC 809C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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


Document Has Been Signed on 08/13/2024 03:21 PM - It Cannot Be Edited

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 II
FACILITY NUMBER: 197608221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) out of six (6) residents physicians's report stated bedridden and facility does not have fire clearance for bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Assistant Administartor agrees to obtain documentation for fire clearance and email LPA all required proof.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/13/2024 03:21 PM - It Cannot Be Edited

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 II
FACILITY NUMBER: 197608221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above could not provide valid insurance at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Assistant Administrator will email current liability insurance to LPA.
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above garage was converted into room with walls and closet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Facility will provide proof of city permits or show application process to LPA via email. Assistant Administrator stated they might tear down room. Proof will be provided with pictures if they decide to do so.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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 II
FACILITY NUMBER: 197608221
VISIT DATE: 08/13/2024
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Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted on 07/16/2024. Infectious control plan was reviewed. The facility had expired liability insurance deficiency cited. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Maria Blanco.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4