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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005745
Report Date: 06/16/2022
Date Signed: 06/16/2022 11:34:06 AM


Document Has Been Signed on 06/16/2022 11:34 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 #5FACILITY NUMBER:
306005745
ADMINISTRATOR:WALTERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:2 BRANDYWINETELEPHONE:
(949) 653-6114
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Cristina Carbungco - Caregiver TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Cristina Carbungco and explained the reason for the visit. During visit, Michelle Nesbitt, RCFE Compliance Manager arrived at 10:50 AM and Administrator Kimberly Walters arrived at 10:45 AM.

At 10:42 AM, LPA toured the facility with Caregiver Cristina Carbungco . Facility is 5 bedroom, 2 bathroom single story home with an attached garage. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility and in their respective rooms. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap and paper towels. LPA observed the screening and sanitizing station in the entrance of the facility. Facility takes residents temperatures daily and documents. The facility mitigation plan has been completed and approved. LPA observed emergency food and water. LPA observed locked medication cabinet. LPA toured the outside grounds and observed outside visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all residents files and all contained required documentation including updated emergency information. All staff and most residents are fully vaccinated for Covid 19.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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