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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850074
Report Date: 05/10/2022
Date Signed: 05/10/2022 04:24:57 PM

Document Has Been Signed on 05/10/2022 04:24 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:CINTHIA MEZAFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 6DATE:
05/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Cinthia MezaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Deficiency visit to the above facility. LPA Ascencio met with Administrator Cinthia Meza at 11:45 AM.

On 5/10/2022, starting at approximately 12:15 p.m., LPA Ascencio reviewed resident files and observed Resident #1 (R1) did not have a Pre-Admission Appraisal. Admin stated they are not sure why they do not have one for the resident. Later that same day, at approximately 12:25 p.m., the LPA did not observed an updated Need and Service plan for R2, R3, R4 for a change in condition. Admin stated that they communicated with the family about the needs verbally. Admin added they were not aware responsible party needed to signed the needs and service plan.

2 citations were issued during today’s visit. The following deficiencies were observed (See LIC 809-D.) and
cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to
correct the deficiencies may result in civil penalties.

Copy of the report and appeal rights provided to Admin via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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Document Has Been Signed on 05/10/2022 04:24 PM - It Cannot Be Edited


Created By: Angel Ascencio On 05/10/2022 at 03:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2022
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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Admin stated they will update the needs and service plan for R2, R3 and R4. Admin will conduct a meeting with resident responsible party letting them know about updated care needs. Admin will provide updated service plan to LPA via email.
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This requirement is not met as evidenced by:
Based on resident records review the licensee
did not comply with the section cited above as
R2 R3 and R4's reappraisal were not done when a change in condition occured, which poses a potential health, safety
and personal rights risk to residents in care.
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Type B
05/24/2022
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
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Admin stated they will complete a Pre-admission appraisal for R1 and present to resident responsible party. Admin will provide copy to LPA via email.
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This requirement is not met as evidenced by:
Based on resident records review the licensee
did not comply with the section cited above as R1 did not have a Pre-Admission Appraisal in their file which poses a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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