<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850074
Report Date: 12/21/2020
Date Signed: 12/22/2020 09:58:00 AM

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:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:KATAPODY, GEORGIAFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 3DATE:
12/21/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Danya FayyadTIME COMPLETED:
01:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing inspection for this proposed facility on 12/21/2020 at 12:43PM. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime" with applicant representative Dania Fayyad. In addition, the residential care facility for the elderly (RCFE) inspection tool was not used during today’s inspection. This is a change of ownership application, but the facility name will remain the same.

A virtual tour of the facility was initiated at 12:50PM with the licensee representative. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted:

The facility consists of 7 total bedrooms – 1 designated for live-in staff use and 6 for resident use as well as 3 bathrooms. Shared facility space includes a common living room, family room, and dining area. There is currently a total of 3 residents residing at the facility. Fire clearance was approved on 11/25/2020 for 6 Bedridden residents.

Fire extinguishers were last serviced on 06/12/2020. This facility has a fire alarm pull system and carbon monoxide detectors, which were checked during an inspection in October 2020. LPA observed all required postings on the wall in the main hallway/entryway.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. Gates were observed to be self-closing and latching. There are no bodies of water on the premises. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: COTTAGE INN
FACILITY NUMBER: 565850074
VISIT DATE: 12/21/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
sufficient amount of perishable and non-perishable food at the facility, properly stored. Cleaning supplies arestored under the sink in a locked cabinet. Knives and sharp objects are in a locked drawer. LPA observed a pantry containing a sufficient amount of emergency supplies. Medication: Medications and resident files are stored in a locked cabinet. Complete first aid supplies are available. Bedrooms: There are 7 total bedrooms in the facility. One is for staff use, and 6 are private resident bedrooms. All 6 client bedrooms were checked and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. Bathrooms: LPA observed all 3 bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have grab bars and non-skid mats. Residents have sufficient amounts of supplies for personal hygiene, which are stored locked. Due to the virtual nature of the visit, the hot water was unable to be measured at the time of the visit. Common Areas: These included the living room, dining area, and family room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. There are 2 fireplaces, both were observed to be adequately screened. Alarms on all common doors were tested and were functional during the visit. LPA observed a cabinet with plenty of activity options for the residents in care. Garage: LPA also observed the locked garage, which contains locked chemical storage, an extra refrigerator/freezer for use with refrigerated medications, washer and dryer.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted via telephone with administrator at 1:45PM. A copy of report was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2