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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005199
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:53:54 PM

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:COTTAGES AT ARTESIA GARDENS, THEFACILITY NUMBER:
306005199
ADMINISTRATOR:AURELIA OLAISFACILITY TYPE:
740
ADDRESS:6041 KINGMAN AVETELEPHONE:
(800) 570-2273
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:55CENSUS: 33DATE:
06/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Aurelia Olais and Diluvan HassanTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report submitted to licensing on 05/21/2021. LPA met with Administrator Aurelia Olais and Prospective Licensee Diluvan Hassan and explained the reason for the visit.

Incident report dated 05/16/2021 indicated Resident 1 (R1) was discovered on another street from the facility at approximately 2AM. R1 eloped out of the facility via exit gate and was located after knocking on a neighbor's door. Once R1 was discovered missing, facility staff drove around looking for R1. Facility called police who advised R1 had been found when the neighbor phoned police. R1 was assessed and no injuries noted. R1 received a medication change as well as antibiotic for a urinary tract infection. Per physician report dated 06/03/2021, R1 is diagnosed with Dementia. This is the first time the resident eloped from the facility and had not been known to be exit seeking.


Based on the observations made during today’s visit, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy along with appeal rights was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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: COTTAGES AT ARTESIA GARDENS, THE
FACILITY NUMBER: 306005199
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited

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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interview and record review, Licensee failed to ensure care and supervision was being provided to R1. R1 eloped out of the facility and was found after knocking on a neighbor's door. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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