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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850074
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:47:12 PM


Document Has Been Signed on 01/19/2023 01:47 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:DANIA FAYYADFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Judith Gonzalez / House Lead. TIME COMPLETED:
01:45 PM
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 At 10:45am on 01/19/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual infection control inspection. LPA met with house lead Judith Conzalez (S1) and announced who he was and the reason for the visit. S1 contacted Licensee Diana Fayyad by phone to confirm that S1 was authorized to conduct and signed for annual inspection visit.

This facility is an eight bedroom, three bathroom, two large living rooms, dining room and kitchen, with a laundry room in the garage. Medications are kept in the hallway cabinet. Staff and resident files are kept locked in the facility office (bedroom #8). There are seating areas outside in the courtyard with shade for residents and visitors. LPA observed the facility water temperature to be with in regulation range of 105*-120* Fahrenheit. LPA observed fire extinguishers throughout the facility and a sprinkler system with fire pull alarm in hallway. LPA noted that the facility to be clean and in good repair. LPA noted that all passageways and exits were clear and free of obstructions. LPA observed more than seven days of non-perishable foods and more than two days of perishable foods on hand. LPA observed at least 30 days of incontinence supplies and at least 30 days of PPE supplies on hand at the facility. LPA noted that all required posting were in an easily accessible location. LPA noted that the there was a Technical Assistance pertaining to the availability of Provider Information Notices (PINs) that was rectified prior to the sending of this report. LPA did not observe any other violations or issued any citations during this part of the annual infection control inspection.
S1 and LPA conducted the annual, infection control module of the annual inspection. LPA noted that the PINs were printed during the inspection that satisfied the technical assistance for that portion of the infection control module. LPA noted that no other violations or citations were assessed as a result of the infection control module of the annual inspection. LPA noted that no violations or citations were issued during the annual, infection control inspection.

Exit interview, report signed and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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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