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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004504
Report Date: 02/18/2022
Date Signed: 02/18/2022 01:01:16 PM


Document Has Been Signed on 02/18/2022 01:01 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:LAGUNA COTTAGE #2FACILITY NUMBER:
306004504
ADMINISTRATOR:RASHIDA KAPASIFACILITY TYPE:
740
ADDRESS:25466 VIA ESTUDIOTELEPHONE:
(949) 542-7696
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rashida KapasiTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Rashida Kapasi. LPA explained the reason for the visit. LPA observed that the living room fireplace is screened. LPA observed the See something say Something poster, PUB 475, does not measure 20" X 26" inches in size. Smoke detectors/carbon monoxide detectors tested operational. LPA and Administrator toured the facility. Facility is a 6 bedroom 5 bathroom house with an attached 2 car garage. One bedroom is for caregivers. LPA observed all of the bedrooms had the required furnishings and were clean and organized. All 5 bathrooms were clean and operational. Hot water temperature in all 5 bathrooms measured between 110.0 degrees Fahrenheit and 118.4 degrees Fahrenheit. LPA observed all medications are kept locked in the kitchen closet. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. The kitchen is clean and organized. All 4 stove burners lighted unassisted. The fire extinguisher in the dining room is fully charged. LPA inspected the first aid kit. The first aid kit did not have scissors or a first aid booklet. At the time of the visit all 6 residents were served lunch. The meal consisted of a salad and tuna casserole and a beverage and half a muffin for dessert. LPA and Administrator toured the backyard. There is a patio with a seating area with a table and chairs for residents to sit outside. There is a shed on the side of the house close to the front entry of the house. The shed is used to store mobility devices, like wheelchairs and walkers and there is a hoyer lift there also. No bodies of water observed. The side of the house with the shed is open to the front and back of the house, there is no gate. On the opposite side of the house there is an exit gate that is operational. No obstacles or hazards observed in the backyard. LPA and Administrator toured the garage. The garage is used for storage of extra food and supplies. The washer and dryer are in the garage. Administrator reported that the garage is off limits to the residents. LPA observed the garage has two rooms with open doorways. Administrator reported the rooms are used for storage. LPA observed both rooms stored clothing and bedding supplies. The garage door is kept locked. Facility has a mitigation plan that is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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