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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600986
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:57:44 PM

Document Has Been Signed on 09/30/2024 03:57 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CLAYTON COTTAGE GLENROSEFACILITY NUMBER:
198600986
ADMINISTRATOR/
DIRECTOR:		CLAYTON, CARYN M.FACILITY TYPE:
735
ADDRESS:3184 NORTH GLENROSE AVETELEPHONE:
(626) 797-7993
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 5DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Direct Support Professional (DSP), Anne Arendpsz and Administrator Cameron ClaytonTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a Required One (1) year annual visit and inspection. LPA met with Direct Support Professional (DSP) who called the Administrator and purpose of the visit stated. Later Administrator joined us. The facility retains five (05) clients with intellectual disabilities, placed by the San Gabriel/Pomona Angeles Regional Center Level IV-G.

LPA conducted physical plant tour inside and out at approximately 12:50PM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom is converted into an office designated for staff use. Disaster drill was last conducted on 07/21/24. Required posting observed in facility (complaint hot line poster, personal rights, etc). There is no body of water in the facility.

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately before entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the office/storage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Linen storage was also checked and observed to have ample supply of clean linen and towels in the hallway. Office designated for staff use maintains snacks, water, emergency kits, extra clothing, personal hygiene, files and overflow of toilet supplies.

(continued to LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLAYTON COTTAGE GLENROSE
FACILITY NUMBER: 198600986
VISIT DATE: 09/30/2024
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(continued from LIC 809)

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 115.0°F to 115.5°F and within the required range. Client’s personal hygiene supplied are kept in their personal space. Common Areas: These included the living room, family room and dining area for clients. The common areas were properly furnished. Furniture in common area was observed to be in good repair. There is one fireplace that is closed and not in use. No obstructions and or tripping hazards throughout the facility. Clients dining table fits five (05) clients.
Kitchen Area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in the cabinet inside the laundry room. Laundry room is located adjacent to the kitchen. Laundry detergent and other toxins are kept in the locked cabinet in the laundry room. Food: LPA observed at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Food storage and preparation areas are clean and inaccessible to pests. Temperature of facility wall thermostat was set at 75.0°F and observed to be within the required range. Fire extinguisher was observed to be located in the laundry room. Fire extinguisher was observed to be operable with service tag dated 09/21/24. Fire alarms are battery operated and observed to be operational. There was a carbon monoxide detector installed in the facility. Medication were observed to be locked, inaccessible and stored in the cabinet in the laundry room. There was a complete first aid kit located inside the laundry room. Knives are locked in the medication cabinet inside the laundry room. Garage is detached to the house and observed to be locked and inaccessible to clients. Garage was converted into a play/meeting room and the other half as a storage for old equipment, frozen and emergency food and other supplies. Client records. All five (5) client records were reviewed. Clients record are complete and current at this time. Staff records were also reviewed. All staff records were reviewed, they all have criminal record clearances and associated to this facility. Staff have current first aid and training documentation showing training completed. Administrator's certificate was observed to be current.

There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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