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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600990
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:47:34 AM

Document Has Been Signed on 10/17/2024 11:47 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COUNTRY COTTAGE 1FACILITY NUMBER:
198600990
ADMINISTRATOR/
DIRECTOR:		POST, KIMFACILITY TYPE:
735
ADDRESS:14508 FONTHILL AVETELEPHONE:
(310) 973-7416
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 3DATE:
10/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator - Kim PostTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 10/17/2024, Licensing Program Analyst (LPA) Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Administrator Kim Post. LPA explained the purpose of the visit.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
3 client records were reviewed and, 2 out of 3 client records had required documentation. 1 client record did not their tuberculosis test result and consent forms. Administrator agrees to complete Client 2’s records.

A technical violation is being recorded regarding shower faucet being in disrepair. Licensee has a maintenance operator working on fixing the shower faucet. A deficiency is being cited based on LPA record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding tuberculosis test results. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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Document Has Been Signed on 10/17/2024 11:47 AM - It Cannot Be Edited


Created By: Socorro Leandro On 10/17/2024 at 11:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 clients did not have a tuberculosis test result, which poses a potential health risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee agrees to send tuberculosis test results for Client 2 and email it to Socorro.Leandro@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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