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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005827
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:36:50 PM


Document Has Been Signed on 11/03/2022 01:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COZY HOME SENIOR CAREFACILITY NUMBER:
306005827
ADMINISTRATOR:DUMALIANG, CZARINA SFACILITY TYPE:
740
ADDRESS:22272 TERNITELEPHONE:
(949) 583-9365
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Czarina DumaliangTIME COMPLETED:
01:55 PM
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On 11/03/2022 at 12:09pm, Licensing Program Analyst (LPA) Jessica Cho arrived at Cozy Home Senior Care to conduct an unannounced Required 1 year visit with an emphasis on Infection Control. At 12:13pm, LPA Cho was greeted and granted entry by Caregiver Violeta Capalla. Also present was Caregiver Joseph Ramil Reid. LPA completed the Coronavirus 2019 (COVID-19) screening procedure. Administrator (Admin) Czarina Dumaliang and Co-Administrator Ser Paris Dumaliang arrived at the facility around 12:55pm. There are no active COVID-19 cases as of today. LPA observed a check-in station that required a COVID-19 screening for all visitors on a sign-in sheet. Facility does not document temperatures on a sign-in sheet. LPA observed the required COVID-19 precautionary signs posted on the front entrance and throughout the facility. The Complaint Poster (PUB475) was in the size of 8.5" x 11" which did not meet the size requirement. The facility is licensed for six non-ambulatory residents of which one may be bedridden and has a hospice waiver for four. There are currently six residents living in the facility of which two are receiving hospice care. The Administrator's Certificate for the Admin expired on 03/09/2022. LPA verified the mandated 50 hours of training was completed during the visit.

At 12:27pm, LPA Cho conducted a tour of the physical plant with Caregiver Violeta Capalla. There are a total of four resident bedrooms and one resident bathroom. There is one private bathroom for the guests and staff. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps. LPA observed hand washing signs in both bathrooms. The hot water temperature measured at 117.8 degrees Fahrenheit in resident Bathroom #1. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and expired on 10/18/2021. A new fire extinguisher was purchased from Home Depot during the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COZY HOME SENIOR CARE
FACILITY NUMBER: 306005827
VISIT DATE: 11/03/2022
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Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Administrator Czarina Dumaliang, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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