<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608221
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:09:51 PM


Document Has Been Signed on 10/05/2023 02:09 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
GREATER LA AC/SC, 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: 4DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Maria Imelda Blanco, Linda Renard Administrators. TIME COMPLETED:
02:18 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
Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with DSP Julie Mejia and Administrator Linda Renard and Maria Blanco show up a short time later and assisted with the inspection today. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for Six (6) non- ambulatory residents. There is a hospice waiver approved for 3 residents. Currently there are 4 residents at the facility.

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

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan at the facility.
Operational Requirements: A current Plan of Operation was reviewed. The facility has a Dementia waiver in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 10/14/2023. The last fire Drill was conducted on 07/20/2023. Care and supervision to meet the residents needs was observed.
Physical Plant & Environment Safety: The facility is a single-story building. Common areas, including the living room, dining room, all appeared clean and were properly furnished. The kitchen was clean and the appliances and fixtures functional. Entry/exits were free of obstruction. The medications were locked in a cabinet in the kitchen. The 4 resident rooms were inspected, and the water temperature measured between 98.4-102.0 degrees F which is not within range of 105.0– 120.1 degrees F. One facet and two screens in resident’s room need to be repaired or replaced.
Staffing: There appears to be sufficient staffing at the facility. The Administrator’s certificate expires 12/20/2024 Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and evidence of on-going training.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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 6


Document Has Been Signed on 10/05/2023 02:09 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
GREATER LA AC/SC, 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: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Water measured 98.1-102.0 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
1
2
3
4
****Water temperature was adjusted during visit, no further action required****
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 10/05/2023 02:09 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
GREATER LA AC/SC, 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: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. One screen in front room and one screen on side of home is in need of repair or replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
1
2
3
4
Administrator will repair or replace screens by POC date and send proof to LPA.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. One facet in the bathroom adjacent to washing machine and dryer is broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
1
2
3
4
Administrator will repair and replace the water facet in small restroom and send proof to LPA by POC date.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE II
FACILITY NUMBER: 197608221
VISIT DATE: 10/05/2023
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
26
27
28
29
30
31
32
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours were posted at facility.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents.
Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed 4 residents' medication files and all medications are administered according to Doctor’s orders. Some PRN were missing labels.
Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Facility needs to update emergency disaster plan.
Residents with Special Health Needs: No residents have prohibited health conditions.

Deficiencies observed during today’s visit. See (809D) technical advisories were provided. An exit interview was held. A copy of this report, 809D, technical advisory notes, and appeal rights were provided to Linda Renard

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6