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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608221
Report Date: 08/31/2026
Date Signed: 09/03/2026 10:54:40 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 10:54 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHLOIE'S COTTAGE IIFACILITY NUMBER:
197608221
ADMINISTRATOR/
DIRECTOR:		LINDA RENARDFACILITY TYPE:
740
ADDRESS:305 E. BASELINE ROADTELEPHONE:
(909) 592-4488
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 6DATE:
08/31/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:21 PM
MET WITH:Khadra Abdelghani, Assistant Admin.TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by facility staff and explained the purpose of the visit. Khadra Abdelghani, Asst. Administrator arrived thereafter.

The facility’s fire clearance is approved for six (6) non-ambulatory residents ages 60 and over. The facility also holds a hospice waiver for three (3) residents.

At the time of inspection, three (3) residents were under hospice care.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is located in a residential neighborhood and is a single-story home consisting of four (4) resident bedrooms, one (1) caregiver bedroom, two (2) bathrooms, one (1) of which is a private restroom located in bedroom four (4), a living room/dining room, kitchen, attached garage, front yard, and backyard. All bedrooms observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. LPA observed that sharps, cleaning supplies, and other toxic substances were inaccessible to residents. Sharps were stored in a kitchen cabinet, and cleaning supplies were secured in a closet near the laundry room. Bathrooms were observed to be equipped with required grab bars near showers and toilets, as well as non-skid mats. Hot water temperature was observed outside the required regulatory range of 105°F–120°F. (continued on 809C)

David Sicairos
Gabriela Castro
DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE II
FACILITY NUMBER: 197608221
VISIT DATE: 08/31/2026
NARRATIVE
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Extra linens and towels were available and stored in a hallway closet. Smoke and carbon monoxide detectors were tested and found operational. Fire extinguishers were observed and available. LPA observed that the door alarms on the exit door near the laundry room leading to the outside and the exit door located in the caregiver corridor were not operational at the time of the visit.

No bodies of water were present on the premises. The backyard and front yard contained shaded seating for residents. Passageways and exits were observed to be clear and unobstructed.

Food Service

Refrigerators and freezers were maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and contained a sufficient supply of food, including at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were stocked.

Health-Related Services & Records

Three (3) resident files were reviewed. Files contained current required documentation including Admission Agreements, signed consents, Needs and Service Plans, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments.

Three (3) residents’ medications were reviewed. Medications were observed to be centrally stored and secured in a locked a living room filing cabinet. During the medication review, LPA observed discrepancies between the Medication Administration Records (MARs) and the medications reviewed.

Disaster Preparedness

Last fire/earthquake drill was conducted on July 1, 2026, with logs available. LIC 610D Emergency Disaster Plan was in process of being updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed.

Personnel Records & Training

Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings.

An exit interview was conducted with Khadra Abdelghani, Assistant Admin. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 10:54 AM - It Cannot Be Edited


Created By: Gabriela Castro On 08/31/2026 at 03:21 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II
FACILITY NUMBER: 197608221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87506(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met by evidence by:
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Licensee shall review and reconcile R1's medications with R1's MAR to ensure all medications are accurately documented and administered as prescribed. Licensee shall submit an updated and accurate MAR for R1, along with a written plan describing how the facility will ensure medication records are maintained accurately and remain consistent with medications on hand. Proof of correction shall by the POC due date.
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Based on medication and record review, LPA observed discrepancies between R1's Medication Administration Record (MAR) and the medications reviewed. The medications on hand did not accurately correspond with the information documented on R1's MAR which poses/posed a potential health, safety or personal rights risk to persons in care
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Type B
08/31/2026
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met by evidence by:
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Licensee shall ensure all required exit door alarms are operational and functioning properly at all times. Licensee shall repair or replace the non-operational door alarms and submit proof of correction, including photographs demonstrating that the door alarms have been repaired or replaced by the POC due date.
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Based on observation during the facility walkthrough, LPA observed that the door alarms on the exit door near the laundry room leading to the outside and the exit door located in the caregiver corridor were not operational at the time of the visit which pose/posed a potential health and safety or person rights to the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
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