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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005233
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:43:00 PM


Document Has Been Signed on 03/28/2024 02:43 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
ORANGE COUNTY ASC, 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: DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Diana Valencia. Administrator Robert James Tramison joined the inspection approximately ten minutes after LPA's arrival.

The facility is a one-story home with six bedrooms, three bathrooms, kitchen, dining room, living room, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted residents were eating lunch at the time of inspection. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Two resident rooms have recliners instead of beds in order to satisfy the preference of the residents. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 106.3, 106.8 and 107.3 degrees Fahrenheit in the three bathrooms. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced in February of 2023. AD stated the facility is getting the extinguishers and fire blanket serviced within the same week of the inspection. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen, hallway and the garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet near the garage. The backyard has four sitting/lounging areas. AD stated some of the umbrellas are in storage due to recent high winds. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA reviewed two client files and medication as well as three staff files. During record review, LPA noted the facility's Infection Control Plan is written on an LIC9283 for Day Programs. LPA advised AD to transfer information on LIC9283 to LIC9282. Facility was unable to produce proof of drills completed during the inspection. A deficiency was issued on this day.

Based on today's inspection one deficiency was issued. An exit interview was conducted and a copy of this report, appeal rights and LIC9282 was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/28/2024 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ADDIE'S COTTAGE SENIOR LIVING INC
FACILITY NUMBER: 306005233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to the facility being unable to produce proof of disaster drills conducted in the last year. This poses a potential safety risk to persons in care
POC Due Date: 04/04/2024
Plan of Correction
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AD stated they will look for the existing drill log and send it to the LPA via email by the assigned POC due date. If AD cannot locate the existing log, the facility will hold a drill and document it in the drill log and send LPA proof of completed drill via email by the assigned POC due date of 4/4/2024. AD stated they will email LPA the completed drill documentation by the assigned POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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