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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701696
Report Date: 05/14/2026
Date Signed: 05/14/2026 03:57:42 PM

Document Has Been Signed on 05/14/2026 03:57 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COZY SENIOR HOMEFACILITY NUMBER:
342701696
ADMINISTRATOR/
DIRECTOR:		PATEL, KETANFACILITY TYPE:
740
ADDRESS:3446 BECERRA WAYTELEPHONE:
(805) 728-0584
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
05/14/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Parveen SaroayTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 5/14/26 at 10:20am Licensing Program Analyst (LPA) Kevin Gould conducted a required post licensing inspection at Cozy Senior Care. LPA met with volunteer, Parveen Saroay and together conducted a tour of the home.

LPA and volunteer evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 115 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed the facility lacked sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed one staff member present without having their criminal record clearance associated to the facility. LPA observed incomplete staff and resident files without signatures or dates. LPA observed missed documentation for medication administration for residents. Facility is in need of appropriate signage that meets regulations.

Per California Code of Regulations, Title 22 the following deficiencies cited during today's inspection. An immediate civil penalty is issued from today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Kevin Gould
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/14/2026 03:57 PM - It Cannot Be Edited


Created By: Kevin Gould On 05/14/2026 at 02:58 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COZY SENIOR HOME
FACILITY NUMBER: 342701696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of associated staff members, the licensee did not comply with the section cited above as one staff member obtained a criminal record clearance but was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Facility will ensure staff is associate prior to their presence in the facility and will provide a written plan of correction, signed by the administrator with a written understanding that no staff members or volunteers may be present without a criminal record clearance and being associated to the facility.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of facility food supplies, the licensee did not comply with the section cited above as the facility lacked the required perishable and non-perishable food supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Facility obtained additional food supplies an will provide a written plan of correction with an updated weekly menus for 4 weeks and provide a written statement that staff preparing foods will be follow a weekly menu that may be subject to changes based resident preferences.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/14/2026 03:57 PM - It Cannot Be Edited


Created By: Kevin Gould On 05/14/2026 at 02:58 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COZY SENIOR HOME
FACILITY NUMBER: 342701696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of resident and staff records, the licensee did not comply with the section cited above as LPA observed several staff and resident files without being completely filled out with required information and without facility representative signature or resident signatures which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Facility has agreed to ensure all documents are complete and signed. A written statement will be provided to the department by the POC date acknowledging all documents are to be complete signed and dated prior to a resident being accepted for care or the on boarding of any new staff. LIC 311F provided for reference.
Type A
Section Cited
CCR
87405(d)(2)
Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, LPA observations and deficiencies observed the licensee did not comply with the section cited above by the number and type of violations observed during the inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Facility will provide a written statement they will accept consultation from the department's Technical Support Program. Once received, LPA will contact TSP for referral.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/14/2026 03:57 PM - It Cannot Be Edited


Created By: Kevin Gould On 05/14/2026 at 02:58 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COZY SENIOR HOME
FACILITY NUMBER: 342701696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of resident's medication administration records, the licensee did not comply with the section cited above as LPA observed two resident records with several dates without documentation of medication administration and no explanation for missed documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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Facility has agreed to provide in-service training for all staff who provide assistance with medications on the importance of timely documentation of medication administration. Documentation of training and staff signature to be provided to the department by 5/29/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
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