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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003765
Report Date: 07/26/2022
Date Signed: 07/26/2022 11:56:00 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/26/2022 11:56 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
CCLD Regional Office, 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:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Carmen Rodriguez, Licensee/Administrator and Annie Gibbs, Office Manager.TIME COMPLETED:
12:09 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Rosie Quiroz was greeted, COVID-19 screened and granted entry into the facility by Live in Caregiver (LCG) Iris Gonzalez . LPA Rosie Quiroz met with Office Manager (OM) Annie Gibbs and Licensee/ Administrator (L/AD) Carmen Rodriguez and explained the nature of the visit. Facility is licensed to provide services to 6 Non Ambulatory residents and has a hospice waiver for 3 residents. Facility is currently providing hospice services to one (1) resident. Administrator Carmen Rodriguez has a current Administrator certificate with expiration date of July 24, 2023.
On or about 11:16am, LPA Rosie Quiroz along with (L/AD) Carmen Rodriguez began the tour of the inside and outside of the facility. There are six residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed six of six residents in dining area getting ready to eat lunch supervised by caregivers. Six of six residents present during today's visit appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility. LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility and a hand washing station in entrance of the facility.
All restrooms observed to have a supply of soap and appeared to be clean. Water temperatures in 2 of 2 bathrooms were recorded to be within normal limits. LPA inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food and water in attached garage area. LPA observed the PPE supply in the facility readily available for use. LPA toured the outside of the facility and observed seating and shaded area for resident and visitor's enjoyment in back yard area. The facility has completed the LIC 808 Mitigation Plan. The plan was received by the Department on April 7, 2021. LIC 808 Mitigation Plan was reviewed and approved by LPA Micah Martinez on April 7, 2021. LPA was informed that all residents and staff have had their COVID-19 vaccinations and one booster. CONTINUED NEXT PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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: IVY COTTAGES I
FACILITY NUMBER: 306003765
VISIT DATE: 07/26/2022
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Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.
This report was reviewed with (L/AD) Carmen Rodriguez, and a copy of this report, and LIC 811 Confidential Names was provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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