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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600229
Report Date: 01/16/2025
Date Signed: 01/16/2025 11:24:48 AM

Document Has Been Signed on 01/16/2025 11:24 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CLAYTON COTTAGE GALENFACILITY NUMBER:
198600229
ADMINISTRATOR/
DIRECTOR:
CARYN M. CLAYTONFACILITY TYPE:
735
ADDRESS:1248 GALEN STREETTELEPHONE:
(626) 357-7586
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 9DATE:
01/16/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Maria Mora, StaffTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Daniel Konishi made an unannounced case management visit regarding a self-reported incident on the relocation of 3 clients Clayton Cottage Glenrose - License # 198600986, 3184 North Glenrose, Altadena, CA 91001 to Clayton Cottage Galen-License # 198600229 due to mandatory evacuation orders from Fire Advisory. LPA met with S1 and explained the purpose of the visit. During the visit, LPA Konishi spoke with the Administrator, Cameron Clayton over the phone and explained the purpose of the visit.

During the visit today, LPA Daniel Konishi conducted a health and safety check, and no concerns were observed. LPA obtained a copy of the client roster for Clayton Cottage Galen and Clayton Cottage Glenrose. LPA obtained a copy of the staff roster for Clayton Cottage Galen but did not obtain a copy of the staff roster for Clayton Cottage Glenrose. The last disaster/fire drill was conducted on 10/14/24.

Per interview with the administrator over the phone, there are 3 clients that have been relocated from Clayton Cottage Glenrose. They have sufficient staffing to meet the needs of the clients. Clayton Cottage Glenrose are providing staffing from their facility to assist residents at Clayton Cottage Galen. Food and hygiene supplies are available to accommodate a total of 9 clients. The facility has 3 bedrooms, 2 bathrooms, 2 living rooms, dining area, and kitchen. The medications and MAR logs for the 3 individuals from Clayton Cottage Glenrose were transferred to the facility and are centrally stored and locked. All the clients in the facility are ambulatory and do not use any assisted devices. All clients in the facility do not require incontinence services. Administrator stated the families, responsible parties, and regional center for Clayton Cottage Glenrose clients have been notified about the relocation either via calls, texts, or emails.

LPA informed administrator to notify the local fire authority of the over capacity and to submit an incident report to appropriate agencies.

An exit interview was held and a copy of this report was given to S1.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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