197610364-3-8-2024-31-AS-TCAS-D36NFZ-20240308092622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610364
Report Date: 03/07/2024
Date Signed: 03/08/2024 09:26:31 AM

Document Has Been Signed on 03/08/2024 09:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANITA'S COTTAGE		FACILITY NUMBER:	197610364
ADMINISTRATOR:	GURULE, MARIO		FACILITY TYPE:	740
ADDRESS:	27736 SYCAMORE CREEK ROAD		TELEPHONE:	(818) 667-8166
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	5	CENSUS: 4	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mario Gurule		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection, LPA was greeted by caregiver Nazrul Sekh, who allowed LPA to enter. There was (1) additional staff on duty, and the Administrator Mario Gurule was present during the visit. The current census is (4). Facility license/sketch, grievance/complaint procedures, personal rights, Infection/Mitigation plan, Administrator certificate, emergency disaster plan, COVID/hand-washing signs, and complaint procedures was visibly posted.

A physical plant tour of the facility inside and outside was conducted with Administrator Mario Gurule. The following common areas: living, dining, kitchen, resident bedrooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen: LPA observed a Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator and freezer stocked with food in the garage. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, that are stored in the kitchen and garage area were locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (5) bedrooms; with (1) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available; as well as personal hygiene products available for residents as well.

Bathrooms: There are (2); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 120.0 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. There was no swimming pools or other bodies of water. All exit doors have alarms; all were operating. Fire extinguisher was checked. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly.

Record review: A complete record review of staff and residents were conducted. All required documents in files.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANITA'S COTTAGE	FACILITY NUMBER: 197610364
	VISIT DATE: 03/07/2024

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Infection/Mitigation Control Review: The common areas were observed to be clean, including resident rooms, and staff and visitor bathrooms. Soap and towels, and hand washing signs were visually posted. The facility has cleaning procedures and protocols in place, which include staff cleaning common areas throughout the day. The facility has documentation of all vaccination records for staff and residents. Temperature check and cleaning station located at the front door.

No citation issued, exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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