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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005746
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:02:40 PM


Document Has Been Signed on 08/10/2022 03:02 PM - 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:
08/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Staff-Reynaldo BacaniTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to the facility. LPA De Perio was greeted and granted entry by staff on duty after temperature was taken, and explained the reason for visit. Staff on duty contacted facility administrator (AD) Alex Valle and Compliance Manager (CM) Michelle Nesbitt who were unable to be present during the time of visit. AD Valle provided consent for staff/caregiver (S1) Reynaldo Bacani to receive and sign report. LPA De Perio observed a total of 3 staff on duty and 6 residents in care, of which 3 are on hospice. Facility is licensed for 6 non-ambulatory residents who are 60 years and older, and a hospice waiver for 3, and 0 bedridden. As of 8/10/22, there are no active COVID cases at facility as verified.

During an annual visit conducted on 7/19/22, there were concerns regarding facility placing cameras in resident bedrooms. During the visit on 7/19/22, it was stated that CM Nesbitt would provide LPA a waiver stating that cameras in bedrooms were allowed, however LPA did not receive any further follow up.

On today's visit, LPA De Perio conducted a tour of the interior portion of the facility with staff on duty and observed functioning cameras to be located in each bedroom.

LPA De Perio spoke to AD Valle and CM Nesbitt via telephone call to follow-up on the waiver, and was informed by AD Valle and CM Nesbitt that they do not have a waiver and that the cameras were "included in the application with licensing".

For this visit, no citation was issued at this time.

An exit interview was conducted with AD Valle, CM Nesbitt via telephone call and S1, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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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