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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610020
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:34:02 PM

Document Has Been Signed on 10/12/2021 03:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:COSTA COLINA IIFACILITY NUMBER:
197610020
ADMINISTRATOR:ADAMS, ASHLEYFACILITY TYPE:
772
ADDRESS:17801 TWILIGHT LANETELEPHONE:
(760) 409-1287
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY: 6CENSUS: 6DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shannon HanakTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Abeye Duguma and Gary Tan met with co-administrator Shannon Hanak for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 10:22 AM and the following was noted:

There are required poster posted at the main door. Screening area is located just outside of the front door. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the back of the house which is outdoors in the smoking area. The facility has sufficient stock of PPE in the storage room.

The facility has 5 bedrooms and 6 bathrooms currently occupying 6 residents. The facility is fire cleared for 6 ambulatory residents.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is body of water (swimming pool) in the facility which is fenced and locked.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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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: COSTA COLINA II
FACILITY NUMBER: 197610020
VISIT DATE: 10/12/2021
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Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature between 72-75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguishers are located in the kitchen and hallways and observed to be full and last inspected on 06/14/2021 and 07/21/2021.

The garage is currently being used as an office and Session room. Laundry room is located in rear of the house adjacent to the Session room. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the storage room. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be in a locked pantry and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Clients have a sufficient amount of personal hygiene product provided by the licensee.



Staff Rooms: Staff room was observed to be locked, located in the converted garage and the rear of the home overlooking the swimming pool. No medications are observed in the staff room.

The bathroom was checked for cleanliness and proper operations. LPA observed non-slip mat in shower. The hot water temperature was measured at a range of 110.5°F to 112.9°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication cabinet to be locked and inaccessible to residents, located in the nurse's office. There is a complete first aid kit located inside the nurse's office.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC809 (FAS) - (06/04)
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