565801589-11-20-2023-29-AS-SURA-CXRNVY-20231120094840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801589
Report Date: 11/16/2023
Date Signed: 11/20/2023 09:49:39 AM

Document Has Been Signed on 11/20/2023 09:49 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
WOODLAND HILLS N.ASC, 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: 5	DATE:	11/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Chrissy Cortez		TIME COMPLETED:	02:55 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with Administrator Chrissy Cortez and explained the reason for the visit.

The LPA and the administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and cleaning supplies are stored in locked cabinets. 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.

BEDROOMS: The facility has 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 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. Auditory devices observed were functioning. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and purchased within the last year on 05/23/2023. There was a linen closet in the hallway with extra towels and linens.

Report continued LIC 809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILYCARE COTTAGE II	FACILITY NUMBER: 565801589
	VISIT DATE: 11/16/2023

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OUTDOOR/GARAGE AREA: The backyard patio is equipped with furniture for residents' use. There is a side gate for client use and is single-latched. No bodies of water were noted. Washer and dryer are in the garage area and were observed to be in operable condition. An additional refrigerator and freezer with perishable food items was observed in the garage. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is locked and inaccessible.

RECORDS: Records review began at 1:25 p.m., 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 2:15 p.m.; medications are centrally stored and locked in a Medications are stored in a locked medicine cart in the kitchen. ; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
-Liability Insurance

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

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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