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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005748
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:51:56 PM

Document Has Been Signed on 07/21/2022 02:51 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 #12FACILITY NUMBER:
306005748
ADMINISTRATOR:TIZON, GERTRUDESFACILITY TYPE:
740
ADDRESS:19105 SIERRA MAJORCATELEPHONE:
(949) 725-1178
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY: 6CENSUS: 5DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Taylor Silva - Caregiver TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Irvine Cottage #12. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Taylor Silva. Caregiver Alexis Silva was also present. LPA Velazquez spoke with Executive Director (ED) Alex Valle on the phone during the visit. The facility is licensed for 6 non-ambulatory residents. The facility also has a Hospice waiver for 3 residents. There are currently 5 residents living in the facility. The last emergency disaster drill was conducted on May 27, 2022. LPA Velazquez was informed that 2 staff tested positive for COVID-19 this week and they are currently isolating at home. There are 2 residents present in the facility that are currently displaying COVID-19 symptoms. ED Valle indicated that the local Department of Public Health has been notified of the COVID-19 positive cases and the facility has implemented their COVID-19 protocol.


At 1:35 PM LPA Velazquez conducted a tour of the physical plant along with Caregiver Taylor Silva. The 1 story home consists of 6 resident bedrooms with 3 bathrooms. The facility also has a living room, family room, dining area, and kitchen. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. 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. LPA Velazquez tested the hot water temperature in 2 of the resident bathrooms and the temperature measured at 100.4 degrees Fahrenheit in the first bathroom and at 114.6 degrees Fahrenheit in the second bathroom.

LPA Velazquez inspected the kitchen along with Caregiver Taylor Silva. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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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 #12
FACILITY NUMBER: 306005748
VISIT DATE: 07/21/2022
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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. The auditory alarms throughout the facility were in operating condition. LPA Velazquez and CG Taylor Silva observed Oxygen in Use signs present in the facility.

LPA Velazquez along with CG Taylor Silva toured the outside grounds. No bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate did have a self-closing latch. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. Resident medications and Medication Administration Records were not reviewed during this inspection.


There were no deficiencies issued during the Required 1 Year inspection. An exit interview was conducted with Caregiver Taylor Silva and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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