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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005744
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:41:43 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/19/2022 11:41 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:IRVINE COTTAGE #10FACILITY NUMBER:
306005744
ADMINISTRATOR:VALLE, ALEJANDRAFACILITY TYPE:
740
ADDRESS:24332 SPARTAN STTELEPHONE:
(949) 458-6083
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nerissa Eslana, House Manager
Vicente Fabella, caregiver
Alejandra Valle, Administraor (via phone)		TIME COMPLETED:
12:00 PM
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On 07/19/2022 at 10:00am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Nerissa Eslana, House Manager and Vicente Fabella, caregiver after explaining the purpose of the visit. Staff present called Alejandra Valle, Administrator. Administrator is isolating at home and could not physically assist with the visit but was able to describe Infection Control measures by telephone to LPA. LPA additionally observed a check-in station at the facility's entrance where visitor temperatures are being documented.

At approximately 10:15am, LPA accompanied by caregiver toured the inside and outside of the facility. There are currently five (5) residents in care, two (2) of which are receiving hospice care. Residents are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The five (5) bedrooms include all necessary components. The bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen cabinet with a functional magnetic lock. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet located in the kitchen. Cleaning supplies are secured in the locked detached garage where the laundry room is also located as well as in a locked cabinet under the kitchen sink. A Technical Advisory is however issued in regard to some additional cleaning supplies belonging to a resident being stored in the shared bathroom. Staff indicates that the resident in question has been informed of storage requirements but have repeatedly refused to comply with the instructions given. An ample supply of linen is observed. LPA observed the facility has COVID-19 Precautions and required department postings. Facility has an adequate supply of PPE. An updated Infection Control Plan has been submitted to the Department.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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 2


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: IRVINE COTTAGE #10
FACILITY NUMBER: 306005744
VISIT DATE: 07/19/2022
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CONTINUED FROM FORM LIC809

Staff present is adequately cleared and associated in Guardian.
LPA toured the outside of the facility and observed it to be free of obstructions. LPA observes a shaded area with patio furniture used by residents and visitors. The two perimeter gates are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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