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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603738
Report Date: 07/10/2024
Date Signed: 07/10/2024 02:22:48 PM


Document Has Been Signed on 07/10/2024 02:22 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:NORTH COUNTY COTTAGEFACILITY NUMBER:
374603738
ADMINISTRATOR:MARI DEE SANDRA CIDFACILITY TYPE:
740
ADDRESS:221 W 6TH AVETELEPHONE:
(760) 743-7133
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:13CENSUS: 9DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Mary Jane Laygo - AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator Mary Jane Laygo, who was informed of the purpose of the visit. At the time of the visit there was three (3) staff and nine (9) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible. The smoke detector and carbon monoxide was inspected by the fire department 11/20/2023 and was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid. Nine (9) resident files were reviewed and possessed all required paperwork which included Admissions Agreement, Pre-Placement Appraisals, and Physician's Report. The listed administrator possesses a current administrator's certificate. Resident medication was centrally stored and locked in a cabinet located in the dining room. A refrigerator to centrally store medication was locked and located in the kitchen. LPA reviewed medications prescribed to the residents and found all medication with required labeling found to be in place. Facility contains infection control plan and emergency and disaster plan. All facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Fire extinguishers were fully charged and inspected. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator Laygo.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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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