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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200565
Report Date: 11/12/2024
Date Signed: 11/12/2024 12:34:15 PM

Document Has Been Signed on 11/12/2024 12:34 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COZY FAMILY CAREFACILITY NUMBER:
079200565
ADMINISTRATOR/
DIRECTOR:		JI, RUIFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(510) 327-4408
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:12 AM
MET WITH:MARILYN PANTONIAL, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 11/12/24 at 9:400 a.m., Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Pre-Licensing visit due to change of ownership. LPA met with Administrator, Marilyn Pantonial (ADM of new Change of Ownership, ADM Rui Ji unavailable) and explained the purpose of the visit.

During the Pre-Licensing visit LPA toured the facility and observed the following deficiencies.

· Lighter, scissors in an unlocked drawer, and scissors in the dishwasher.

· Facility dose not have enough food. Purchase food non-perishable and perishable.

· Staff living in the garage storage room.

· missing screen on the kitchen window.

· unlocked medication in garage storage/bedroom.
  • unlocked Round-up weed killer in the backyard.

continue on LIC 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COZY FAMILY CARE
FACILITY NUMBER: 079200565
VISIT DATE: 11/12/2024
NARRATIVE
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continue from LIC 809
  • fruit picker in the back yard.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $500.00 civil penalty will be assessed on today's date for staff living in the garage storage room.*

Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 12:34 PM - It Cannot Be Edited


Created By: Carol Fowler On 11/12/2024 at 11:31 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COZY FAMILY CARE
FACILITY NUMBER: 079200565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2024
Section Cited

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Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following:
This requirement is not met as evidenced by:
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Based on observation staff is using the garage storage room for living quarters which poses a potential health and, safety or personal risk to persons in care.
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Type B
11/16/2024
Section Cited

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(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above in having a minimum of 7 day non-perishables and 2 day perishables which poses a potential health, safety or personal rights risk to persons 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 12:34 PM - It Cannot Be Edited


Created By: Carol Fowler On 11/12/2024 at 11:43 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COZY FAMILY CARE
FACILITY NUMBER: 079200565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited

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87705 Care of person with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above in having a lighter in an unlocked drawer in the and scissors in the dishwasher. Round-up and a fruit picker unlocked located in the backyard unlocked. This poses an immediate health and safety or personal risk to persons in care.
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Type A
11/13/2024
Section Cited

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Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.
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Based on LPA observed unlocked medication was stored in the storage room/staff living quarters in the garage
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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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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