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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005735
Report Date: 06/17/2021
Date Signed: 06/17/2021 08:59:42 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:
06/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Maricar De GuzmanTIME COMPLETED:
09:08 AM
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Licensing Program Analyst (LPA) Jim August conducted an unannounced visit to Irvine Cottage II. The purpose of today's Case Management visit is to confirm staff 1 (S1) is no longer working and/or present at the facility. LPA August was allowed entry into the home and met with Caregiver Maricar De Guzman and Gerarvo De Guzman. Both caregivers were unaware of who S1 was. LPA toured the entire physical plant and did not see any other employees.

Based on evidence obtained during today's visit, LPA August has verified S1 is not present, employed, or residing at the facility. No deficiencies were cited today.

An exit interview was conducted with Maricar De Guzman and a copy of this report along with the LIC 811 was provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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