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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600990
Report Date: 03/05/2025
Date Signed: 03/05/2025 10:12:27 AM

Document Has Been Signed on 03/05/2025 10:12 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 4DATE:
03/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Kim Post, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 03/05/2025, Licensing Program Manager (LPM) Ulysses Coronel, and Licensing Program Analyst (LPA) Jose Anguiano, conducted an unannounced visit and met with Administrator Kim Post, and the purpose of the visit was explained.

During todays visit LPM and LPA conducted a tour of the facility, conducted staff interviews and reviewed facility and staff records. Interview's revealed that LVN Nathaniel Hatfield (LVN1) was hired and provided care and supervision to clients at this facility on February 6, 2025 as a facility nurse. House Manager Latoya Manuel stated that LVN1's work schedule is Sundays through Tuesdays from 7:00pm to 7:00am and worked at Country Cottage 1 last night.

Regional office record reviews indicate that LVN1's criminal record exemptions is still pending and is not yet approved. Title 22, Division 6, Chapter 1 is being cited and a civil penalty is being assessed, please see LIC809D and LIC421BG.

An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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Document Has Been Signed on 03/05/2025 10:12 AM - It Cannot Be Edited


Created By: Jose Anguiano On 03/05/2025 at 09:01 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2025
Section Cited
CCR
80019(e)(4)

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Criminal Record Clearance. All individuals ...shall prior to working, residing or volunteering in a licensed facility: Request and be approved for... a criminal record exemption,...facility.
This requirement was not met as evidenced by:
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The adminisitrator agreed to review Guardian records prior to allowing staff to work and immidiately remove LVN1 from staff schedule and remove them from the facility's staff association in Guardian. Proof of correction will be submitted via to jose.aguiano@dss.ca.gov
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Based on staff interviews and records reviews staff Nathaniel Hatfiled provided care and supervision prior to getting his crimminal record excemption approved which poses an immidiate health, safety and personal rights risk to clients in care.
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Jose Anguiano
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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