565801589-10-23-2024-29-AS-KDUK-DABUY8-20241023155931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801589
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:59:35 PM

Document Has Been Signed on 10/23/2024 03:59 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FAMILYCARE COTTAGE II		FACILITY NUMBER:	565801589
ADMINISTRATOR:	DEBRA BRYANT		FACILITY TYPE:	740
ADDRESS:	389 RAMBLE RIDGE DR.		TELEPHONE:	(805) 492-1200
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	10/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Marisol Flamenco		TIME COMPLETED:	04:05 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 02:25PM. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Designee Marisol Flamenco arrived shortly thereafter. Entrance interview conducted.

RECORDS: Records review began at 02:34PM. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 02:55PM; medications are centrally stored and locked in a medicine cart in the kitchen. Medications are labeled and checked for expiration dates. Medications for 2 (two) residents were observed. Both residents' medications were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility has an infection control plan and emergency disaster plan; both of which were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 08/13/2024.

Beginning at 03:11PM, the LPA and Administrator Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was observed to be fully charged and Administrator Designee stated was recently purchased, around the time of LPA Chochian's last visit. LPA Dulek advised Designee to retain proof of purchase date. All combination smoke and carbon monoxide detectors were functional during testing.

Report continued LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILYCARE COTTAGE II	FACILITY NUMBER: 565801589
	VISIT DATE: 10/23/2024

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BEDROOMS: The facility has 6 (six) private residents' bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility does not have a staff room.

RESTROOMS: There are 2 (two) common restrooms for residents' use, both were clean and sanitary and in operating condition with hand soap and paper towels. The hot water temperature tested in the common bathrooms within the approved limits.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be screened and inaccessible to residents in care. Auditory devices on exit doors were observed and functioning. There was a linen closet in the hallway with extra towels and linens, as well as a closet containing activity supplies.

KITCHEN/GARAGE: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are stored in a locked medicine cart in the kitchen. The garage was observed adjacent to the kitchen. The garage contains locked storage for knives and other sharps. There are also separate storage areas for food, hygiene items and cleaning supplies, as well as laundry area, emergency food and water. The garage is locked and inaccessible.

OUTDOOR AREA: The backyard patio is equipped with furniture for residents' use. There is a side gate for resident use and is single-latched. No bodies of water were noted. All passageways were noted to be clear and free of hazards.

The LPA reviewed the following documents:

- LIC9020 Client Roster
- Liability Insurance

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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