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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005233
Report Date: 03/28/2022
Date Signed: 03/28/2022 11:53:18 AM


Document Has Been Signed on 03/28/2022 11:53 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:ADDIE'S COTTAGE SENIOR LIVING INCFACILITY NUMBER:
306005233
ADMINISTRATOR:RUTH TRAMISONFACILITY TYPE:
740
ADDRESS:2582 E SEVILLE AVETELEPHONE:
(714) 248-7222
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Teresa Garcia, Caregiver
Ruth Tramison, Administrator		TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver and LPA explained the nature of the visit. Ruth Tramison, Administrator arrived shortly after and met with LPA.

LPA Martinez began the tour of the inside and outside of the facility. LPA observed a check in station in the main entry of the facility. Facility staff is taking temperatures daily and documenting the results. There are six residents in care and there are no active covid-19 cases in the facility. LPA observed three residents in living room watching television and remainder of residents in their bedrooms. All residents appeared to be clean and well taken care of. LPA observed required Department postings, covid-19 precautionary postings in the facility. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected residents’ bedroom and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the facility to have an emergency food and water supply as well as PPE supply in the facility. LPA toured the outside of the facility and observed several seating areas for residents’ enjoyment. LPA was advised that all staff and residents’ have received their Covid booster shots.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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