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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003765
Report Date: 08/15/2024
Date Signed: 08/22/2024 04:03:54 PM


Document Has Been Signed on 08/22/2024 04:03 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:IVY COTTAGES IFACILITY NUMBER:
306003765
ADMINISTRATOR:CARMEN RODRIGUEZFACILITY TYPE:
740
ADDRESS:9856 MARIPOSA AVENUETELEPHONE:
(714) 965-0412
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Carmen RodriguezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 1:15 PM. During today’s visit, LPA met with Carmen Rodriguez, Administrator (AD).

The facility is a seven bedroom, single story building with an approved fire clearance of six non-ambulatory and a hospice waiver for three residents. The facility currently has a census of six residents in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. All resident rooms had the required furnishings and half-bedrail orders were in resident records. The hot water temperature measured between 105.0 and 113.1 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on August 12, 2024. The facility’s last fire drill was conducted on June 12, 2024.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on May 21, 2026.

(See LIC 809-C)
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IVY COTTAGES I
FACILITY NUMBER: 306003765
VISIT DATE: 08/15/2024
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(See LIC 809)

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date.

An exit interview was conducted with Carmen Rodriguez, AD and a copy of the report, LIC 9102-TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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