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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530167
Report Date: 02/23/2024
Date Signed: 02/23/2024 11:03:00 AM


Document Has Been Signed on 02/23/2024 11:03 AM - 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:VENUS' COZY COTTAGEFACILITY NUMBER:
365530167
ADMINISTRATOR:RUDER, VENUSFACILITY TYPE:
740
ADDRESS:2955 IRVINGTON AVENUETELEPHONE:
(562) 508-6698
CITY:SAN BERNADINOSTATE: CAZIP CODE:
92407
CAPACITY:6CENSUS: 0DATE:
02/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Venus Ruder - AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an announced visit to complete the Pre-licensing inspection. LPA met with Venus Ruder, Administrator, and discussed the purpose of the visit.
The application is for a Residential Care Facility for the Elderly (RCFE). A fire clearance was granted by the San Bernardino County Fire Department on 9/15/23 for a total capacity of six (6) residents. Five (5) non-ambulatory residents, one (1) resident may be bedridden. LPA toured the interior and exterior areas of the facility. The following were inspected:

Physical Plant: The physical plant is consistent with floor plan submitted by the facility. Indoor and outdoor passageways were kept free of obstructions. The facility has no swimming pools or similar bodies of water. No firearms are stored at the facility. The facility has operating night lights, fire alarm/carbon monoxide alarms, telephone service, laundry equipment and door signal system. The facility has sufficient bed linen, towels, and personal hygiene supplies.

Resident bedrooms: Resident bedrooms were equipped with clean mattresses/linens, nightstands, chairs, storage space and lighting.

Resident bathrooms: Resident bathrooms were equipped with grab bars, non-skid strips, and operating bathroom equipment. The hot water temperature tested at 111 degrees F.

Food Service/Dining Areas: Kitchen area is kept clean and odor free. Utensils and dishware are in good repair and ready for resident use. The refrigerator and freezer were operating in a healthful manner. Sharps, cleaning solutions, and other toxins were kept locked and stored away from food items. The dining area located near the kitchen has sufficient space for resident use.

Medication: The location for medications storage was kept locked.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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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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: VENUS' COZY COTTAGE
FACILITY NUMBER: 365530167
VISIT DATE: 02/23/2024
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Activities: The facility has sufficient indoor and outdoor space for activities. Backyard activity space is enclosed with self-latching gates. The facility has a sufficient supply of activities for resident use.

Postings: The facility has posted in the entry area, emergency exit plans, theft and loss policy, Licensing Complaint poster, Ombudsman poster, Resident Personal Rights, and Resident Council Rights.



Overall, the facility is clean and in good repair. The Pre-licensing inspection and Comp III presentation is complete; no corrections to the facility are required.

An exit interview was conducted where this report was discussed and a copy of this report was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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