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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005735
Report Date: 11/10/2020
Date Signed: 11/17/2020 09:58:41 AM

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:IRVINE COTTAGE #2FACILITY NUMBER:
306005735
ADMINISTRATOR:WALTERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:16 PORTERTELEPHONE:
(949) 654-1150
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 6DATE:
11/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Administrator Kimberly WaltersTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Criss Trinidad and Patricia Velazquez contacted the facility via telephone to conduct a Case Management visit telephonically due to the COVID-19 Pandemic and pre-cautionary measures. LPAs Trinidad and Velazquez spoke with Administrator Kimberly Walters, identified themselves, and discussed the purpose of the visit. The purpose of this Case Management visit was to follow-up on a special incident report (SIR) received on November 5, 2020 regarding Resident (R1) received by LPA Trinidad.


At 2:20 PM LPAs Trinidad and Velazquez along with Ms. Walters conducted a virtual tour utilizing FaceTime of the interior of the facility. LPAs also conducted a staff interview. LPAs also requested copies of pertinent records from the files of (R1).

There were no deficiencies issued during this Case Management visit. An exit phone interview was conducted with Kimberly Walters and a copy of this report was signed by LPA Criss Trinidad. This report will be sent via email to Ms. Walters who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Ms. Walters agrees to return the sign report.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss TrinidadTELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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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