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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005199
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:50:32 AM

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: 34DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Auerlia Olais and Dillon HassanTIME COMPLETED:
12:20 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 07/30/2021. LPA met with Administrator Aurelia Olais and Prospective Licensee Dillon Hassan and explained the reason for the visit.

Incident report dated 07/27/2021 indicated Resident 1 (R1) was found right outside the facility by a caregiver at approximately 7:04 PM. Resident was escorted back to the facility and assessed to have no injuries. Per physician report dated 05/21/2021, R1 is diagnosed with Dementia and has wandering tendencies. Incident report, same date, indicated that Resident 2 (R2) was found by Buena Park Police wandering on Beach Blvd. R2 was brought back to the facility and assessed to have no injuries. Administrator states R2 was gone for approximately one hour. Per physician report dated 03/28/2021, R2 is diagnosed with Dementia and has wandering tendencies. Facility investigation revealed the delayed egress gate was not functioning properly and did not alarm. Facility maintenance has since repaired the gate and LPA observed the gate is currently operational. During the visit, LPA observed both residents sleeping in the facility.

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: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
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 did not ensure care and supervision was provided to Residents 1 and 2. Both residents eloped out of the facility on 07/27/2021 due to a faulty gate. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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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: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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