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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005531
Report Date: 04/18/2024
Date Signed: 04/18/2024 11:53:40 AM


Document Has Been Signed on 04/18/2024 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:ELLA'S COTTAGEFACILITY NUMBER:
306005531
ADMINISTRATOR:JOINER, KERRYFACILITY TYPE:
740
ADDRESS:17698 SANTA TERESA CIRTELEPHONE:
(714) 321-5150
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Kerry Joiner, Licensee, Sophia Ramirez, Administrator and Diane Mahinay, Assistant AdministratorTIME COMPLETED:
11:57 AM
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On today's date, Licensing Program Analysts (LPAs) LPA Rosie Quiroz and LPA Rose Ruppert made an unannounced visit on this day for the purpose of conducting an Annual Required-1 year inspection visit. LPAs were greeted by House Manager (HM) Cecille Peterson and met with Licensee Kerry Joiner and discussed purpose of today’s visit. Administrator (AD) Sophia Ramirez and Assistant Administrator (AAD) Diane Mahinay arrived during today’s visit.
The facility is a one story home which consists of: 2 private resident bedrooms, 2 shared resident bedrooms, 1 caregiver bedroom, 2 bathrooms for residents, 1 bathroom for visitors and staff, 1 shower room, living-room, family room, kitchen with dining area, back yard with ample shade and outdoor furniture, garage with operational washer and dryer.
The facility is licensed for age range 60 and over, approved for capacity of 6 Non-Ambulatory residents, of which 1 may be bedridden and has a hospice waiver for 6 residents. There are currently (2) two residents receiving hospice care services.
Administrator Sophia Ramirez has a current Administrator's certificate which expires on 8/5/2024.
LPAs along with Licensee Kerry Joiner and AAD Mahinay toured the interior and exterior of facility. LPAs observed kitchen for proper sanitation and cleanliness. LPAs observed sharp objects locked and secured in cabinet in kitchen area, and observed toxin substances to be locked and inaccessible to residents in care in locked and secured closet in garage area. The food was observed to meet the minimum requirement of two days perishable and seven days nonperishable food supply for residents in care.
Six of six resident bedrooms were observed to have required furnishings including but not limited to: lamp, bed, mattress, night stand and clean linen. LPAs interacted and interviewed 6 of 6 residents during facility tour. The water temperature in resident bathrooms were measured to be within 118.0- 119.8 degrees Fahrenheit. The Grab bars and non-slip mats were observed in resident bathrooms and shower room. Room temperature inside the facility was recorded to be 71 degrees F.

CONTINUED NEXT LIC 809-C PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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: ELLA'S COTTAGE
FACILITY NUMBER: 306005531
VISIT DATE: 04/18/2024
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CONTINUED... The outside grounds were inspected during facility tour, and no bodies of water were observed. No pool available at this facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
While inspecting backyard area, LPAs observed unstable gate on northwest of facility. Licensee indicated property landlord will come out to inspect on today's date and schedule repair. (SEE LIC-9102 TA)
LPAs observed a fire extinguisher mounted and charged in kitchen area, which was last serviced on 4/11/2024. LPAs observed and tested functional and operational carbon monoxide and smoke alarms.
(AD) Sophia Ramirez reports fire drills are conducted quarterly with staff and residents. Last facility fire drill was conducted on 3/27/2024.
AAD Mahinary reported facility has an activity coordinator and reported offering the following indoor and outdoor activities at the facility according to weather conditions: "walks, music therapy, lunch in the backyard, bingo, holiday/birthday gatherings, family activities and dancing." LPA Quiroz reviewed whether the facility is operating within capacity limitations and reviewed repeated violations, no repeated violations assessed.
During today's visit, LPAs reviewed six of six resident records, centrally stored medications and four personnel files. Resident and personnel files were found to be within Title 22 California Code of Regulations.

Based on the observations made during today’s visit; there are no deficiencies being cited per Title 22 Division 6 of the California Code of Regulations. LIC 9102 Technical Assistance issues during today's visit. This report was read and reviewed with AD Ramirez and AAD Mahinart, and a copy of this report, LIC 858s, LIC 859 and LIC 9102-TA were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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