<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005747
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:28:38 PM


Document Has Been Signed on 07/26/2022 04:28 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 #4FACILITY NUMBER:
306005747
ADMINISTRATOR:VALLE, ALEJANDRAFACILITY TYPE:
740
ADDRESS:7 PRINCETONTELEPHONE:
(949) 654-4764
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Alejandra Valle, Administrator
Michelle Nesbitt, Compliance Manager
Estelita Augustin, caregiver
Dairwil Manapsal, caregiver		TIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/26/2022 at 3:30pm, 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 Estelita Augustin and Dairwil Manapsal, caregiving staff. Administrator Alejandra Valle and Michelle Nesbitt arrived later to assist with the visit. All staff present is adequately cleared and associated with the facility.

At approximately 3:45pm, LPA accompanied by caregiver Estelita Augustin toured the physical plant of the facility. There are currently five (5) residents in care, one (1) of which is receiving hospice care. Residents are observed participating in activities in the dining room or relaxing in their respective bedrooms 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. The facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen drawer with a functional magnetic lock. LPA observed a sufficient supply of food and water present. The central storage of medication is located in a locked cabinet. Facility has a minimum of 30 days of medication available. Cleaning supplies are secured in the attached garage. A sufficient supply of linen is observed. LPA observed required department postings and COVID precaution posters on display. Facility has an adequate supply of PPE available. LPA toured the outside of the facility and observed outdoor furniture in a shaded area on the patio for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises and backyard is free of obstructions and debris

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: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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 1