565850074-1-18-2024-29-AS-KDUK-CZLRDE-20240118115549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850074
Report Date: 01/18/2024
Date Signed: 01/18/2024 11:55:58 AM

Document Has Been Signed on 01/18/2024 11:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COTTAGE INN		FACILITY NUMBER:	565850074
ADMINISTRATOR:	DANIA FAYYAD		FACILITY TYPE:	740
ADDRESS:	191 WAYVIEW CT		TELEPHONE:	(805) 650-7497
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 5	DATE:	01/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Judith Gonzalez, Facilty Designee		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:14AM. LPA met with facility staff/Designee Judith Gonzalez. Administrator was contacted via telephone and was unavailable during today's visit. Entrance interview conducted.

Beginning at 09:57AM, the LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and last serviced on 03/20/2023. Hardwired combination smoke detectors/carbon monoxide detectors, as well as sprinkler system are professionally inspected annually, with the last inspection conducted on 03/10/2023. No safety concerns were noted in the report provided. No fire clearance concerns were observed during today's visit.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives and all sharps are stored in a locked cabinet under the kitchen sink. All cleaning supplies are stored in a locked hallway closet.

COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened.

BATHROOMS: There are three (3) bathrooms for shared resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured and was found to be in compliance with regulation.

Report Continued on 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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: COTTAGE INN	FACILITY NUMBER: 565850074
	VISIT DATE: 01/18/2024

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BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated for private resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, additional chemical storage and emergency food and water.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: Began at 09:38AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 10/10/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATION REVIEW: Began at 10:20AM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident.

During the visit, LPA obtained copies of the following documents:

LIC 500
liability insurance

No deficiencies cited. Exit interview conducted with Facility Designee. A copy of today's 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

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