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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005748
Report Date: 07/02/2021
Date Signed: 07/02/2021 10:54:48 AM

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 #12FACILITY NUMBER:
306005748
ADMINISTRATOR:TIZON, GERTRUDESFACILITY TYPE:
740
ADDRESS:19105 SIERRA MAJORCATELEPHONE:
(949) 725-1178
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY:6CENSUS: 6DATE:
07/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresita PalilengTIME COMPLETED:
11:00 AM
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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.

LPA began the tour of the facility upon entry. The facility currently has 6 residents in care. LPA observed there was 4 residents in living room relaxing before activity time. All residents appeared happy and well taken care of. Facility was observed to be clean and sanitary. Facility staff screened LPA upon entry, and it was observed that facility has a check in station in main entry of facility. LPA reviewed the covid documentation log binder for all staff and resident. At 9:30am LPA tested the hot water temperature in bathrooms which are used by the residents. The hot water temperature was measured at 108.9 Fahrenheit degrees. LPA observed there is an ample supply of emergency food and water as well as first aid kits. The facility has covid precautionary postings through out the facility as well as all required Department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. Facility has PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and in all common spaces. LPA toured the outside of the facility and observed a shaded outside space for residents/visitors. Facility has a plan for covid testing residents and staff as needed a plan as well for isolation as needed. Facility bedrooms are currently 4 bedrooms are single occupancy and 1 bedroom is shared.

Based on the observations 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 to 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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