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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003825
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:42:53 PM


Document Has Been Signed on 03/21/2022 03:42 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
347003825
ADMINISTRATOR:ANGELINA SOMARJAIFACILITY TYPE:
740
ADDRESS:5643 CLARK AVENUETELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 2DATE:
03/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angelina Somarjai, Administrator TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection while also delivering complaint findings to an unrelated complaint. LPA met with Judith Duncan, caregiver, who contacted the Administrator, Angelina Domarjai, who arrived around 2:55 pm to the facility. Caregiver on site confirmed there are (2) residents currently, and no residents are on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA was informed (1) resident is at a medical appointment and (1) resident is napping in her room.

LPA recently discussed the incident when resident (R1) fell on 3/7/2022 just outside the front entrance, by phone on 3/16/2022, after receiving a completed incident report (LIC624) by fax. Resident had just moved to the facility on 3/6/2022 and had a confusing moment the morning following moving into the facility.

Resident was sent out immediately for further medical examination due to sustaining skin abrasions on her hands and knees. Resident returned the same day and attended a doctor appointment the following day. Administrator requested Home Health services be started to include physical therapy and nursing due to the fall and skin abrasions. Administrator indicated that resident has mild cognitive impairment and very quickly exited the front door, even though there are alerts that sound when the door is opened.

Resident is adjusting better to moving to the facility and has not tried to exit again.

Resident is doing well and was attending a follow up doctor appointment during today's inspection. LPA spoke to resident and her family member at 3:40 when she returned to the facility.

There are no deficiencies being cited. Copy of report provided to Administrator.


SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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