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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005611
Report Date: 05/16/2022
Date Signed: 05/17/2022 08:37:36 AM


Document Has Been Signed on 05/17/2022 08:37 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:BEECHWOOD COTTAGE, THEFACILITY NUMBER:
306005611
ADMINISTRATOR:OTBO, INES NFACILITY TYPE:
740
ADDRESS:1608 BEECHWOOD AVETELEPHONE:
(714) 255-7917
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Ines Otbo, AdministratorTIME COMPLETED:
06:05 PM
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Licensing Program Analyst (LPA), Kathrina Chin conducted an unannounced visit for the purpose of conducting a required annual visit. LPA met Michelle Otbo, Administrator and explained the purpose of the visit.

LPA Chin toured the facility. There are five residents residing in the facility and two are on hospice. LPA observed required postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. LPA reviewed the mitigation plan of the facility.

Smoke detectors, carbon monoxide and auditory exit alarms were tested and were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 106.7 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, the facility had a covered and patio furniture.


No deficiencies cited this review as per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Michelle Otbo, Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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