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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:24:26 PM

Document Has Been Signed on 05/31/2022 03:24 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COTTAGE LLC, THEFACILITY NUMBER:
547202420
ADMINISTRATOR:SIEGEL, DELENAFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Diana BradleyTIME COMPLETED:
03:28 PM
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On 5/312022, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA met with Administrator, Diana Bradley and stated the purpose of the visit. COVID-19 guidelines are in place, visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door.

Facility inspection conducted. Six (6) residents present during today's inspection. Residents observed to be watching TV, coloring, and relaxing in the bedrooms during facility tour. Facility appeared clean, good lighting, sufficient seating available for all residents in care. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, resident bedrooms with 2 occupants observed to have a minimum of 6 feet between beds. All medication observed to be locked and secured in hallway closet. Residents observed to have a 30-day supply of medication available. Food supply observed to be adequate. No obstructions of fire clearance observed. PPE supply available on site.

Fire extinguisher present and has a service date of 10/01/2021. Carbon monoxide detector and smoke detectors present and observed to be operational during today's inspection.

LPA received copies of First Aid card, LIC 500. Administrator to submit updated Administrator Certificate when received.

No deficiencies observed during inspection.

Exit interview conducted. Facility report signed at time of inspection. Copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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