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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002938
Report Date: 12/07/2023
Date Signed: 12/07/2023 01:04:22 PM


Document Has Been Signed on 12/07/2023 01:04 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Aida BrionesTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the CARE inspection tool. LPA met with Administrator Aida Briones, and explained the purpose of the visit. LPA observed two additional caregivers presence at the facility.

LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six private resident rooms, three bathrooms, one staff room, laundry room, kitchen and common areas. LPA observed the facility to have 2+ days of perishable and 7+ days of non-perishable foods. LPA observed knives and medications to be locked and secured. LPA observed the presence of activities available in the facility.

LPA and Administrator discussed ensuring all exits are not blocked. Additionally, LPA and Administrator discussed ensuring a night light or other lighting is available in the hallway for visibility. Additionally, LPA and Administrator discussed submitting a LIC 200 and facility sketch for a bedridden clearance.

File review of four personnel records and three resident records were reviewed. LPA found files to be complete with the required documents.

At this time, LPA is requesting a copy of LIC 500 and liability insurance to be emailed to LPA at Administrator's earliest convenience.

During today's inspection, LPA completed the inspection tool and found the facility to be in compliance. No deficiencies cited.

Exit interview and a copy of the report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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