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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600229
Report Date: 11/16/2021
Date Signed: 11/16/2021 11:40:17 AM

Document Has Been Signed on 11/16/2021 11:40 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CLAYTON COTTAGE GALENFACILITY NUMBER:
198600229
ADMINISTRATOR:CARYN M. CLAYTONFACILITY TYPE:
735
ADDRESS:1248 GALEN STREETTELEPHONE:
(626) 357-7586
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Federico Cardenas / DSP
Administrator Caryn Clayton		TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Annual visit using the Infection Control Evaluation Tool. Upon arrival LPA met with Federico Cardenas / DSP. The Administrator, Clayton Caryn, arrived shortly after to assist with the visit. The facility is licensed to serve six (6) developmentally disabled ambulatory adults between the ages of 18-59. Currently, there are four (4) clients in placement. LPA observed two (2) clients at the time of this visit.
There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility is located in a residential area. LPA toured the home and inspected 3 client bedrooms, 2 bathrooms, kitchen, dining area, living room, family/activity room, indoor/outdoor activity areas. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathrooms and measured between 106.2F - 107.1F degrees which is within the required 105F - 120F degrees. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions and toxins are in a secured cabinet and inaccessible to residents. All medications for residents are kept locked and inaccessible to other There is a detached two car garage with additional storage of food supply.

Report continues on 809C




SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLAYTON COTTAGE GALEN
FACILITY NUMBER: 198600229
VISIT DATE: 11/16/2021
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The garage door is kept locked and inaccessible to clients at all times. Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a pull-switch fire alarm in the living room. The fire extinguisher was observed in the family/activity room and was fully charged and in compliance. The first-aid kit is fully stocked w/First-aid Manual. LPA observed signs to wear a mask and other Covid 19 prevention protocol signs were posted throughout the facility as well as hand washing, cough etiquette, physical distancing and other necessary signs.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. residents. The washer and dryer are located in the kitchen area.

Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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