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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002233
Report Date: 05/10/2022
Date Signed: 05/10/2022 01:53:34 PM


Document Has Been Signed on 05/10/2022 01:53 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:RAINBOW COTTAGEFACILITY NUMBER:
306002233
ADMINISTRATOR:HANH PHAMFACILITY TYPE:
740
ADDRESS:24301 LYSANDA DRIVETELEPHONE:
(949) 455-7376
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Imelda Navarro, Ma AlojadoTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual (mitigation) inspection in this facility. LPA was greeted and granted entry by Caregivers Ma Alojado and Imelda Navarro, and LPA completed the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and toured the facility with both caregivers.

The facility is a single level structure and licensed for six non-ambulatory residents and has a hospice waiver for four residents. There is one resident in hospice care as of today. For this visit, there are six residents in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms tested operational. LPA observed exposed wires in the dining room and hallway. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 127.1 degrees Fahrenheit in Bathroom #1, 123.9 degrees Fahrenheit in Bathroom #2, and 124.1 degrees Fahrenheit in Bathroom #3. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. LPA observed sharp items were inaccessible to the residents in care, and LPA observed medications and cleaning supplies were accessible to the residents in care. Two prescription medications were observed in Bedroom #1 and 3 spray bottles of bleach were observed in Bathroom #2 which were removed and locked away. The fire extinguishers were mounted and charged. For the exterior portion, facility had outdoor furniture in the attached sun room. Per Administrator (Admin) Hanh Pham, the sun room was built in 2021 and LPA observed through record review that the building permit was acquired in 08/20/201. LPA received a copy of the building permit during the visit. LPA did not observe an updated floor plan reflecting the changes of the added sun room. LPA requested an updated floor plan to the Admin. The exterior grounds were free of tripping hazards and the side exit door was self-latching and self-closing. LPA reviewed the approved COVID-19 Mitigation Plan.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: RAINBOW COTTAGE
FACILITY NUMBER: 306002233
VISIT DATE: 05/10/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.


For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and the licensee will follow-up with the corrections. An exit interview was conducted with Caregiver Imelda Navarro, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
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
LIC809 (FAS) - (06/04)
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