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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005746
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:19:25 AM


Document Has Been Signed on 07/19/2022 11:19 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 #14FACILITY NUMBER:
306005746
ADMINISTRATOR:TIZON, GERTRUDESFACILITY TYPE:
740
ADDRESS:19462 SIERRA CHULATELEPHONE:
(949) 725-0748
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 6DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Michelle NesbittTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Irvine Cottage #14. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. At 9:40 am, LPA Cho was allowed entry into the facility and met with Caregiver (CG) Lolita Bacani after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Reyneldo Bacani was also present. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility is licensed for six non-ambulatory residents. The facility also has a Hospice waiver for three residents. There are currently six residents living in the facility of which three are in hospice care.

Around 10:05 AM, LPA Cho conducted a tour of the physical plant along with CG Bacani. Compliance Manager (CM) Michelle Nesbitt arrived at the facility at 10:34 am for the interview. The single story home consists of five resident bedrooms with two resident bathrooms. There is one staff break room and private bathroom. The facility also has a living room, dining area, and kitchen. The six residents in the facility appeared well-groomed and well cared-for. LPA Cho observed the Complaint Poster in the correct size. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA observed a camera in five resident bedrooms. LPA requested to provide documentation that the cameras were approved by the Department. CM stated that the documents will be provided via email later today. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. The required hand washing signs were observed in all three bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 107.0 degrees Fahrenheit in Bathroom #1 and 108.3 degrees Fahrenheit in Bathroom #2.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
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 #14
FACILITY NUMBER: 306005746
VISIT DATE: 07/19/2022
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LPA Cho inspected the kitchen along with CG Bacani. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents/clients. The auditory alarms throughout the facility were in operating condition.

LPA Cho along with CG Bacani toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the side gate was self-closing and self-latching. There were no security bars or weapons on the premises.

LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply stored in the garage. The First Aid Kit had all the required components, and the facility had sufficient PPEs stored in the closet.


No resident or staff files were reviewed at the time of this visit. LPA reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. Two facility tablets are provided to residents upon request.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Compliance Manager Michelle Nesbitt, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
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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