198600986-9-9-2021-31-AS-RVAA-C6PQNS-20210909121937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600986
Report Date: 09/09/2021
Date Signed: 09/09/2021 12:19:56 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2021 12:19 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:	CLAYTON COTTAGE GLENROSE		FACILITY NUMBER:	198600986
ADMINISTRATOR:	CLAYTON, CARYN M.		FACILITY TYPE:	735
ADDRESS:	3184 NORTH GLENROSE AVE		TELEPHONE:	(626) 797-7993
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 6		CENSUS: 6	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Maria Biguerias, Staff		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with Staff Maria Biguerias and explained the reason for the visit. A tour of the physical plant was conducted at 9:16am and the following was noted: 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, and masks are available. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. 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 backyard. The facility has sufficient stock of PPE in the storage room. The facility has three (03) bedrooms and two (2) bathrooms currently occupying six (06) residents. Three (03) rooms are shared rooms. (continued on LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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: CLAYTON COTTAGE GLENROSE	FACILITY NUMBER: 198600986
	VISIT DATE: 09/09/2021

NARRATIVE

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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. A fire extinguisher is located in the kitchen. It was last serviced in January of 2021.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is also a storage room at the backyard being used to store food and other supplies.

Laundry area is located by the kitchen, laundry detergents, cleaning agents and other toxins are stored in a cabinet underneath the kitchen sink which were observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 118.7 degrees. There was enough clean linen available in stock at the cabinet.

Medications-LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There is one ( 01) complete first aid kit located in the kitchen.

Exit interview conducted. A copy of this report was issued and signature obtained.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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