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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600986
Report Date: 09/18/2022
Date Signed: 09/18/2022 04:32:17 PM

Document Has Been Signed on 09/18/2022 04:32 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 GLENROSEFACILITY NUMBER:
198600986
ADMINISTRATOR:CLAYTON, CARYN M.FACILITY TYPE:
735
ADDRESS:3184 NORTH GLENROSE AVETELEPHONE:
(626) 797-7993
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 5DATE:
09/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Cameron ClaytonTIME COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with Cameron Clayton and explained the reason for the visit.

A tour of the physical plant was conducted at 03:10pm 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.

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 five (5) residents. Two (02) rooms are shared rooms and one (01) room is currently a private room.

(continued on LIC 809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2022
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: 09/18/2022
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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 74 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 September of 2022.

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 116.5 degrees. There was enough clean linen available in stock in 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: 09/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2022
LIC809 (FAS) - (06/04)
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