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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600990
Report Date: 09/26/2022
Date Signed: 10/13/2022 08:58:40 AM

Document Has Been Signed on 10/13/2022 08:58 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COUNTRY COTTAGE 1FACILITY NUMBER:
198600990
ADMINISTRATOR:POST, KIMFACILITY TYPE:
735
ADDRESS:14508 FONTHILL AVETELEPHONE:
(310) 973-7416
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 3DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kim Post, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Fatima Dinsmore, House Manager, and later met with Kim Post, Administrator and the purpose of today’s visit was explained.

There are currently (3) West-side Regional Center consumers in placement. All (0) clients are ambulatory (3) non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry area in the attached garage.

LPA, Administrator, and House manager toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1-4 are occupied by clients and contain the mandated furniture. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide are inter-connected are compliant and operational. No firearms are stored at facility and no bodies of water present. The water temperature is at 107.1 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, (2) fire extinguishers are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990
VISIT DATE: 09/26/2022
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 During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet and computer for clients to use, clients temperatures are checked and logged (3x a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All clients and staff are vaccinated and boosted.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An Technical Advisory (TA) issued.


1. Cart for PPE's.

Due to time constraint's, LPA will continue the annual on a later date.

An exit interview conducted with Kim Post, Administrator and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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