<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002233
Report Date: 06/17/2024
Date Signed: 06/17/2024 04:43:17 PM


Document Has Been Signed on 06/17/2024 04:43 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
ORANGE COUNTY RO, 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:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Imelda Navarro- Lead Caregiver
Ma Alojado- Caregiver		TIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection using the Care Inspection Tool. LPA Cho was greeted and granted entry by Caregiver Ma Alojado and stated the purpose of the visit.

The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory and maintains a hospice waiver of four (4). There is one (1) resident under hospice care on today's visit.

LPA toured the interior and exterior portions of the facility. There are a total of five resident bedrooms and three resident bathrooms. There is also one staff bedroom and a private staff sun room. There is an additional sun room for the residents. LPA observed the facility to be clean and sanitary. The resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke/carbon monoxide detectors and auditory exit alarms were tested and operational. LPA observed bathrooms to be in good repair, provided with handrails, and a non-skid floor mat. The hot water measured at 116.4, 119.1, and 118.9 degrees Fahrenheit in the resident bathrooms. Facility met the two day perishable and seven day non-perishable food supply. LPA observed medications, toxins, and sharps were inaccessible to the residents. The fire extinguisher was serviced on 08/08/23. For the exterior portion, facility had sufficient seating and shading. The exit door was self-closing and self-latching. LPA observed the emergency disaster supplies including food/water. LPA observed the required "See Something, Say Something' (PUB475) posters in the required size.

LPA conducted an audit of six residents' files and two staff files. Discrepancies noted. Staff interviews were conducted. Resident interviews were not conducted due to residents were busy at the time of the interview. Medications were audited for four residents. No discrepancies noted.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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


Document Has Been Signed on 06/17/2024 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: RAINBOW COTTAGE
FACILITY NUMBER: 306002233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in four out of six residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
1
2
3
4
Administrator stated that proof of doctor's orders for four residents will be submitted to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/17/2024 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: RAINBOW COTTAGE
FACILITY NUMBER: 306002233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)&(b)(1)
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in five out of the six residents for completing the medical asessments and two out of six residents for TB test results which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
1
2
3
4
Administrator stated that proof of Physician's Report and TB test results will be submitted for five out of six residents to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: RAINBOW COTTAGE
FACILITY NUMBER: 306002233
VISIT DATE: 06/17/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA consulted the following: to obtain a doctor's order for the half rail beds for four (4) residents as well as a physician's reports for five (5) residents, obtain a Tuberculosis Test (TB) for two residents, and to pay the annual licensing fee that was due on June 14, 2024.

Based on the observations made during today's visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with Caregivers Imelda Navarro, and Ma Alojado, and a copy of this report including the LIC809C, LIC809Ds, LIC811, and the appeal rights were provided during this visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4