<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603340
Report Date: 08/21/2020
Date Signed: 08/25/2020 08:47:45 AM

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:FIDLER COTTAGEFACILITY NUMBER:
198603340
ADMINISTRATOR:AVILA, GLENDAFACILITY TYPE:
740
ADDRESS:2874 FIDLER AVETELEPHONE:
(424) 241-4625
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: DATE:
08/21/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Heidi SkilesTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Jade Jordan, made an announced visit, and met with the Applicant/ Administrator Heidi Skiles to conduct a Pre-Licensing evaluation on Friday August 21, 2020, at 11:30 am.

An application was submitted to Community Care Licensing Department (CCLD) on 03/16/2020 for an initial application to serve Individuals over ages 60 years and above. The requested capacity is for six (6). Of which Five (5) are non- ambulatory clients, and one (1) is a bedridden client. Structure: Facility is a one-story family home with five (5) bedrooms, (2) full bathrooms, Open spaced , living room, dinning room, office and kitchen. Washer/Dryer appliances are located laundry storage space located in the hallway going towards bathroom.. A one (1) car locked garage is located in the front of the property, and will be used for storage inaccessible to residents. Front yard landscape is in good condition at time of visit. Bedroom Residents: There shall be no more than two residents per bedrooms. Bedrooms #1 is shared, Bedroom #2-5 are private Bedrooms #4 is for (1) bedridden client. Bedrooms are equipped with one bed ( except room rm#1 which has two), night-stand, chair, overhead lightning. Bedroom 1, and 5 are in the back of the house, and bedroom 2, 3 are located in the front of the house, and bedroom # 4 is located on the left of the house.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FIDLER COTTAGE
FACILITY NUMBER: 198603340
VISIT DATE: 08/21/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
. Bedroom Staff: There will be no live-in staff. Bathrooms: Two (2) bathrooms have a working toilet, wash basin, bath-tub/shower. There are two (2) bathrooms that will accommodate non-ambulatory residents. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads, all rooms have required mattress pads. Ample supply of linen is stored in the closet hallway. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are not yet posted, will be posted in the open floor plan next the hallway. Facility has a land line telephone located in the office area, currently active. There are three (3) fully charged fire extinguishers. Food Service: Dishes, and flatware are stored in the kitchen cupboards, inspected and in good repair, Knives, cutlery, and other sharp kitchen utensils will be stored under kitchen sink locked cabinet. Ample food supply is stored in the kitchen and consists of the following: 7-day non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors/Carbon Monoxide(s): There are 8 electrical & connected smoke detectors and 2 carbon monoxide; located throughout the facility fully operational. Appliances: Stove burners (gas) oven, dishwasher, microwave, and washer/dryer are in working condition. There are two (2) refrigerator in the home; located in the kitchen, and garage. The residence is equipped with central heat/air conditioning. Toxins: Cleaning supplies, and toxins will be located in locked laundry cabinet only accessible to staff. Water Temperature: Hot water was tested in bathroom # 2 at 107.d which is within normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in the locked pantry, resident files will be in a locked cabinet next to office. Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files will be located in locked office file cabinet. Applicant will not handle cash resources of clients. Reading Material, Games, Equipment & Materials: The facility has board games, puzzles books, and other recreational materials for the client's use. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 03/31/2020 does not advise of any delayed egress features and/or any locked perimeters.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: FIDLER COTTAGE
FACILITY NUMBER: 198603340
VISIT DATE: 08/21/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Component III:
Component III was completed at the Pre-Licensing on Tuesday, 08/21/2020 at 4:00PM . Information provided about how to operate the facility within substantial compliance. The following individuals Heidi Skiles, Administrator participated. When the applicant /administrator was asked if they have understood Title 22 she responded in the affirmative.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau(CAB ) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3