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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005827
Report Date: 11/23/2022
Date Signed: 11/23/2022 11:29:43 AM

Document Has Been Signed on 11/23/2022 11:29 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, 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:
11/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Czarina DumaliangTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit to the facility today in conjunction with a complaint investigation. LPA arrived at facility was greeted at the door by staff and was granted entry. LPA spoke with facility staff. Czarina Dumaliang, Administrator arrived shortly after and met wtih LPA, LPA explained the nature of the visit.

This visit is to conduct an investigation to complaint number 22-AS-20221118171111. During the course of this visit LPA checked criminal record clearance/association for facility for S1 and S2. Records review for S2 reflect that there is no record of facility association. S2 informed LPA that S2 began working at the facility on today's date 11/23/22 and today was first day at facility. Therefore, an immediate civil penalty is being assessed.

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC809-D for deficiencies. An immediate civil penalty is assessed.

This report was reviewed with Administrator and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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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Document Has Been Signed on 11/23/2022 11:29 AM - It Cannot Be Edited


Created By: Ruth Martinez On 11/23/2022 at 10:42 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COZY HOME SENIOR CARE
FACILITY NUMBER: 306005827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced
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Admnistrator acknowledges and agrees to associate S2 and submit an LIC9182 along with copy of ID. Administrator to forward proof of correction to LPA by POC due date.
civil penalty assessed*
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by: Based on observation, interviews, and record review, the facility did not ensure one of two staff were associated to the facility as required prior to employment which poses an immediate Health, Safety, or Personal Rights risk to persons 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:Sheila Santos
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022


LIC809 (FAS) - (06/04)
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