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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005746
Report Date: 07/02/2021
Date Signed: 07/02/2021 12:53:30 PM

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 #14FACILITY NUMBER:
306005746
ADMINISTRATOR:TIZON, GERTRUDESFACILITY TYPE:
740
ADDRESS:19462 SIERRA CHULATELEPHONE:
(949) 725-0748
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 5DATE:
07/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Michelle Nesbitt, Compliance Manager TIME COMPLETED:
01:02 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. LPA explained the nature of the visit to caregiver. Compliance manager for facility arrived shortly after.

LPA began the tour of the facility accompanied by caregiver. The facility currently has 5 residents in care. LPA observed there was 3 residents in living room relaxing and 1 resident in their bedroom. LPA observed facility to be clean and sanitary. Upon entry facility staff screened LPA, it was observed there is a check in station in entry of facility for screening. LPA reviewed documentation in regard to covid for all the staff and residents. At 11:35am LPA tested the hot water temperature in bathrooms used by the residents. The hot water temperature was measured at 108.7 Fahrenheit degrees. LPA observed the facility has covid precautionary postings through out the facility as well as all required Department postings. Facility maintains an active covid-19 prevention plan in place for the safety of all residents in care. LPA observed the facility has an ample supply of food and water. It was observed facility has first aid kits in facility. LPA observed facility has PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through the facility. LPA toured the outside and observed there are two shaded seating areas for resident’s enjoyment as well for the use of visitors. Facility has a plan for covid testing residents and staff and for isolation as needed. Facility has 4 bedrooms that are private occupancy and 1 bedroom that is shared.

Based on the observation made during today’s visit, no deficiencies were noted today 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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