<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005392
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:24:13 PM


Document Has Been Signed on 03/22/2024 03:24 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:TAYLOR COTTAGE, THEFACILITY NUMBER:
306005392
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:7752 TAYLOR DRIVETELEPHONE:
(614) 746-5824
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:6CENSUS: 6DATE:
03/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Weenie EarwoodTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/22/2024, Licensing Program Analysts (LPA) Jenifer Tirre, Edward Kim and Licensing Program Manager (LPM) Lourdes Montoya conducted an unannounced required continued Annual visit using the CARE Inspection Tool. LPA’s & LPM were greeted by Staff and granted entry after stating the purpose of the visit. Administrator (Admin) Mary Jean Catacutan was not present to assist with the facility inspection on today's date. Licensee Weenie Earwood came to facility to assist with inspection visit.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for three (3) residents and (1) bedridden. Currently, there are three (2) Hospice residents present during today’s visit.

This is a single story with a two-car garage facility. The facility has five resident bedrooms, one staff bedroom, and three full bathrooms.

At around 9:15AM, LPA’s & LPM conducted a tour of the physical plant accompanied by Licensee Earwood, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 106.1 degrees F. A comfortable temperature of 69 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has one fire extinguisher which is fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392
VISIT DATE: 03/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE).

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on January 10, 2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 11/8/2023 - 11/8/2024. The facility is current on Community Care Licensing annual dues.

A review of three residents (R1-R3) service files and one out of three staff (S1) personnel files revealed to be incomplete. The facility has the current administrator's certification on file for Mary Jean Catacutan # 6036186740 - Expiration 8/2/2025.

Based on the observations made during today's visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Licensee Weenie Earwood.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 03/22/2024 03:24 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three out of five residents missing updated physician's reports and appraisal records for residents with Dementia (R1-R3) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Licensee agreed to complete Resident records for R1, R2 and R3. Licensee will submit proof of correction to department via email at jenifer.tirre@dss.ca.gov by POC due date 4/5/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 03/22/2024 03:24 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
87305 Alterations to Exisiting building or new facilities (a) prior to construction or alterations all facilities shall obtain a building permit.

This requirement is not met as evidenced by: Licensee failed to notify department of structural alterations to resident bedroom.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one of five resident rooms which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Licensee agreed Inquire from the city and to provide proof of building permit if needed via email at jenifer.tirre@dss.ca.gov by POC due date 4/5/2024
Type B
Section Cited
CCR
87307(a)(2)(C)
87307 Personal Accommodations and Services (a) living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accomodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by: resident's room is a passageway to staff room.
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in one out of five resident rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Licensee agree to provide a separate exterior entrance for staff bedroom and remove access from resident bedroom to staff bedroom. by POC date 04/05/2024.
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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 03/22/2024 03:24 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the followinginformation:(11) a Health screening as specified in section 87411, Personnel Requirements- General.

This requirement is not met as evidenced by: Facility is missing health screening and TB test
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Licensee agreed to provide updated personnel records for all personnel staff by POC due date 4/5/2024
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/22/2024 03:24 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements-General (c) All RCFE staff who assist residents with personal activites of daily living shall receive initialand annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff is missing CPR certification in personnel file which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Licensee agreed to provide updated CPR documentation for Staff 1 via email to jenifer.tirre@dss.ca.gov by POC due date 4/5/2024
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6