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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600990
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:41:16 PM

Document Has Been Signed on 10/11/2024 02:41 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
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: 4DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Administrator - Kim PostTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/11/2024 at around 1:20 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Kim Post. LPA explained the purpose of the visit and was accompanied by the House Manager inside and outside the facility during this inspection.

This facility is licensed to serve 4 non-ambulatory adults ages 18 – 59 years.

A total of 4 clients are currently residing in this facility.

The facility has a balance of $454 due on 11/07/2024 of Annual Licensing Fees.

The facility is a one-story house located in a residential street. The home consists of 4 client bedrooms, 2 bathrooms, 1 entry room/living room/dining room/kitchen area, 1 backyard patio area with shaded seating, and 1 attached garage.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990
VISIT DATE: 10/11/2024
NARRATIVE
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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. There are fire extinguishers, and they were last serviced on 04/22/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

4 out of 4 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Adequate lighting and toiletries accessible to clients.This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990
VISIT DATE: 10/11/2024
NARRATIVE
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No deficiencies were cited.

LPA was unable to complete annual inspection due to time constraints.

An exit interview was conducted, and a copy of this report was left with the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
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