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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002938
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:18:29 PM


Document Has Been Signed on 02/24/2023 02:18 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
345002938
ADMINISTRATOR:BRIONES, AIDA R.FACILITY TYPE:
740
ADDRESS:5643 CLARK AVE.TELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
02/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Aida BrionesTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit. LPA met with Licensee, Aida Briones, and explained the purpose of the visit.

Prior to entering the facility, LPA observed the front metal gate to be in the middle of the driveway. LPA was informed the gate was broken, a result of the storm the night prior. Licensee stated it was too heavy for staff and Licensee to remove, and a third party will be arriving in the afternoon to fix the gate.

Additionally, LPA observed a mattress present on the side of the facility at the exit fence. Caregiver informed LPA it has been discarded on the side of the facility for about two weeks.

As a result of today's inspection, deficiencies were observed. Please see attached LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was emailed to Licensee.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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 02/24/2023 02:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: COZY HOME CARE
FACILITY NUMBER: 345002938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited

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87303 Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by:
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Licensee moved the mattress immediately and placed the mattress in the back of the facility for Monday trash pick up.
Licensee is to submit a photo proof that mattress has been picked up by March 3, 2023.
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Based on observation and interview, Licensee did not ensure solid waste was disposed appropriately as LPA observed a mattress discarded on the side of the facility and was infromed it has been there for approxiamtely (2) weeks, which posed a potential risk to the health and safety of residents 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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