306005598-9-14-2022-22-AS-ETAA-CJ9QMZ-20220914121822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005598
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:18:32 PM

Document Has Been Signed on 09/14/2022 12:18 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 - LINCOLN		FACILITY NUMBER:	306005598
ADMINISTRATOR:	EMETERIO-PARUNGAO, MARIA		FACILITY TYPE:	740
ADDRESS:	825 N LINCOLN ST		TELEPHONE:	(714) 912-4929
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 6	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Corazon Ramos, Igmedio "Jojo" Laxamana Jeremy "Jay" Parunago		TIME COMPLETED:	12:30 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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Corazon Ramos Igmedio “Jojo” Laxamana and stated the purpose of this visit. Administrator Jermery “Jay” Parungao arrived during the inspection and provided assistance. The facility is a single-level structure licensed for six non-ambulatory with a hospice waiver for five and one may be bedridden. This facility offers Residential Care for the Elderly. At about 10:50 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 6 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 6 private resident rooms and a staff room which is inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured between 120.0 – 120.9 degrees Fahrenheit. LPA is aware of the warmer temperatures that would affect the water temperature. For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards. Facility offers a 2-car garage which is used for storage and an operational washer/dryer and refrigerator. Fire alarms, carbon monoxide alarms and auditory exit alarms were tested to be operational. Fire extinguisher was observed. Kitchen was in good repair. LPA noticed knife drawer did not have a lock. Administrator was made aware of this issue and will purchase a lock for the knifes/sharps. Administrator was made aware of annual fee due on 09/30/2022. Administrator paid annual fee and was provided with a confirmation number.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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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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 - LINCOLN	FACILITY NUMBER: 306005598
	VISIT DATE: 09/14/2022

NARRATIVE

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LPA Tapia viewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult 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.

For this visit, one deficiency was noted in areas observed. No advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Jeremy “Jay” Parungao and copy of this report along with appeal rights were explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/14/2022 12:18 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JC COTTAGES - LINCOLN	FACILITY NUMBER: 306005598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

This requirement is not met as evidenced by: The following shall be stored inaccessible to residents with dementia. Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one knifes were left unlocked in the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2022
	Plan of Correction
1 2 3 4	Administrator will purchase a lock for the knife drawer in the kitchen.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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