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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005576
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:49:55 PM


Document Has Been Signed on 05/13/2022 01:49 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:JC COTTAGES - HOLLYDALEFACILITY NUMBER:
306005576
ADMINISTRATOR:PARUNGAO, MARIAFACILITY TYPE:
740
ADDRESS:1013 N HOLLYDALE DRTELEPHONE:
(714) 519-3927
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 5DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jay ParungaoTIME COMPLETED:
01:55 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
Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the required annual (mitigation) inspection. LPA was greeted and granted entry by Caregiver Justino Elesterio after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and began the tour of the facility with Caregiver Elesterio. The Administrator (Admin) Jay Parungao joined at 1:05 pm.

The facility is a single level structure and licensed for 5 non-ambulatory and 1 bedridden resident; and has an approved waiver for 6 hospice residents. As of today, there is 1 resident in hospice care. LPA observed 2 staff on duty and 4 residents resting in the living room and 1 resident sleeping in their bedroom. LPA observed the required department postings at the front door and all around the facility as well as hand washing signs in the restrooms. LPA observed all restrooms had ample soap/sanitizer and appeared clean. Bathrooms were provided with grab bars and non-skid floor mats; and observed to be in good repair except the cabinets underneath the sink as they did not lock properly. Residents' bedrooms appeared clean and sanitary and had all required components. Smoke detectors, carbon monoxide, and auditory exit alarms were tested and operational. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medication and sharp items were inaccessible to the residents in care, however the Ajax was observed in the sink cabinet in Bathroom #2. The Ajax was removed during the visit. Fire extinguishers were mounted and charged. For the exterior portion, facility had patio furniture under ample shading. LPA observed the emergency disaster and evacuation plans. Facility does have back-up emergency food and water supply and has a 30 day supply of PPEs. The First Aid Kit had all the required elements.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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 3


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: JC COTTAGES - HOLLYDALE
FACILITY NUMBER: 306005576
VISIT DATE: 05/13/2022
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
LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Jay Parungao, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3