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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880626
Report Date: 11/05/2024
Date Signed: 11/05/2024 01:34:29 PM

Document Has Been Signed on 11/05/2024 01:34 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JCP COTTAGEFACILITY NUMBER:
361880626
ADMINISTRATOR/
DIRECTOR:
FRISCO SANRYFACILITY TYPE:
740
ADDRESS:14241 LA MIRADA STTELEPHONE:
(760) 780-0970
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Sevi Turangan- LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Arie Makarawung and introduced self and stated the purpose of the visit. Arie notified the Licensee, Sevi Turangan over the phone about the LPA's purpose of the visit. LPA was informed that there are currently 5 residents in care.

The facility has 6 bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry, backyard, and attached garage. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms appliances were found functional. LPA observed a broken mirror in the hallway bathroom, a dirty bathtub and sink in the bathroom of the master bedroom and a broken side gate door on the left side of the backyard. Deficiency issued. LPA observed that the master bathroom did not have a non-skid mat in the bathtub. Deficiency issued. LPA observed a staff assist a resident in the bathroom with the door left opened. Deficiency issued. Water temperatures tested at 107.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, CCL complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. LPA observed a cleaning product made accessible to residents inside the master bedroom bathroom and the magnetic key left accessible in the kitchen cabinet. Deficiency issued. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345
DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 11/05/2024 01:34 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: JCP COTTAGE

FACILITY NUMBER: 361880626

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in making the cleaning product in the master bathroom and magnetic key on the kitchen cabinet accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee made the magnetic key and cleaning product inaccessible. Licensee stated that she will train staff on regulation cited and submit proof of attendance sheet to LPA via email by 11/19/24.
Section Cited
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing a staff assist a resident without background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee stated that the staff without background clearance will not be volunteering in the facility as of today. Licensee will submit a statement of understanding on regulation cited by 11/12/24 via email to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: JCP COTTAGE

FACILITY NUMBER: 361880626

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not having an Infection Control Plan available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee stated that she will download, complete and submit the Infection Control Plan to LPA via email by POC due date.
Section Cited
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by providing proof of an active liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee stated that she will submit proof of an active liability insurance to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2024 01:34 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: JCP COTTAGE

FACILITY NUMBER: 361880626

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by maintaining a broken mirror on the hallway bathroom, dirty bathtub and sink in the bathroom of the master bedroom and a broken side gate door on the left side of the backyard in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee stated that she will repair the broken mirror on the hallway bathroom and side gate door on the left side of the backyard, and clean the dirty bathtub and sink in the bathroom of the master bedroom. Licensee will submit pictures and video as proof to LPA via email by POC due date.
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by maintaining a non-skid mat in the master bathroom bathtub which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee stated that she will purchase a non-skid mat and place it in the master bedroom bathtub and submit picture of item and receipt to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: JCP COTTAGE

FACILITY NUMBER: 361880626

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(c) Individual privacy shall be provided in all toilet, bath and shower areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not providing privacy to resident when they were using the bathroom by having staff leave the door open which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee stated that she will train staff on regulation cited and submit proof of attendance sheet to LPA via email by POC due date.
Section Cited
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing proof of a physical test on the health screening of a staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee stated that she will have staff see a physician to complete a physical test and submit proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2024 01:34 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: JCP COTTAGE

FACILITY NUMBER: 361880626

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing proof of emergency drills conducted quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee stated that she will train staff on regulation cited and submit proof of attendance sheet to LPA via email by POC due date.
Section Cited
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not reviewing/updating the Emergency Disaster Plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee stated that she will download, complete and submit a copy of the Emergency Disaster Plan to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JCP COTTAGE
FACILITY NUMBER: 361880626
VISIT DATE: 11/05/2024
NARRATIVE
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard and one shed used for storage.

Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed a health screening missing the physical clearance, doctor's signature and stamp. Deficiency issued. LPA observed a staff assist a resident from the bathroom without background clearance. Deficiency with civil penalty issued. LPA observed that a staff member had background clearance and was removed from facility association. Technical violation issued. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed one resident's admission agreement printed on double sided. Technical violation issued. LPA observed that the facility did not have an Infection Control Plan available for review. Deficiency issued. LPA observed that the facility did not have proof of liability insurance. Deficiency issued. LPA observed that the facility did not have a record of emergency drills. Deficiency issued. LPA observed that the facility did not review/update the emergency disaster plan since 10/19/21. Deficiency issued.

Deficiencies, technical violations and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV. LIC421BG and appeal rights were discussed and copies were provided to Licensee, Sevi Turangan.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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