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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609897
Report Date: 01/28/2022
Date Signed: 01/28/2022 08:32:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNLAND COTTAGEFACILITY NUMBER:
197609897
ADMINISTRATOR:ORTIZ-LUIS,RHEAFACILITY TYPE:
740
ADDRESS:10942 QUILL AVETELEPHONE:
(818) 395-0517
CITY:SUNLANDSTATE: CAZIP CODE:
91040
CAPACITY:6CENSUS: 4DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Annie BasilanTIME COMPLETED:
01:00 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and arrived at the facility at 10:00 am. LPA was greeted at the front door by the caregiver, Annie Basilan and observed caregiver was wearing a mask. LPA's temperature was recorded and LPA was asked to sign in. The sign in station contained hand sanitizer, masks, and a sign in sheet. The caregiver confirmed there are four residents. Upon entering the facility, LPA observed two residents sitting in the living room. The Caregiver stated the Administrator, Rhea Ortiz-Luis was attending a meeting and was away from the facility.

The tour began at 10:15 am and LPA observed comfortable seating in the living room. A dining room table with chairs was located in the dining room. Upon entering the kitchen, LPA observed wash your hands sign, hand soap, paper towels, and a trash can. LPA observed the refrigerator contained fresh vegetables, fruits, and eggs. The freezer contained frozen meets. At 10:20 am, LPA observed the knives were not locked in a kitchen drawer. LPA stated to caregiver the knives should be locked in the cabinet. LPA observed cleaning disinfectants unlocked under the sink. LPA also explained the importance of cleaning supplies securely locked in a safe area.

LPA observed the bedrooms were neat and clean. The rooms contained a bed, linens, chair, night stand and lamp. There are two bathrooms in the facility and both contained wash your hands sign, hand soap, paper towels, trash can, and slip resistant mat. The backyard has a shaded area which contained comfortable furniture. The washing machine and dryer are located in the garage. The gate leading to the front yard was unlocked. LPA observed a supply of N-95 masks, gloves, and hand sanitizer.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNLAND COTTAGE
FACILITY NUMBER: 197609897
VISIT DATE: 01/28/2022
NARRATIVE
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LPA observed a hallway cabinet which contained fresh linens and the medications were locked in a file cabinet within the kitchen area. At 11:31 am, LPA observed the residents were social distanced at the kitchen table eating lunch which consisted of meat with fresh vegetables, rice and watermelon.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issued to the Caregiver.


SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNLAND COTTAGE
FACILITY NUMBER: 197609897
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by
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Based on LPA's observations while conducting a tour of the facility, the licensee did not comply with the section cited above as knives were found in a kitchen drawer and the drawer was not locked which posed an immediate health risk to persons in care.
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Type A
01/28/2022
Section Cited

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The following items shall be made inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. LPA observed cleaning supplies in unlocked cabinet under the kitchen sink.
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Based on LPA's observations while conducting a tour of the facility, the licensee did not comply with the section cites above as cleaning supplies such as bleach were observed accessible to residents which posed an immediate health risk to persons in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3