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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005749
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:57:07 PM

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 #9FACILITY NUMBER:
306005749
ADMINISTRATOR:MCALEER III, JAMESFACILITY TYPE:
740
ADDRESS:20271 ORCHIDTELEPHONE:
(949) 533-5938
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 6DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Mary Melchor, Alex Valles, and Michelle NesbittTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Mary Melchor and explained the reason for the visit. Executive Director Alex Valles and Compliance Manager Michelle Nesbitt arrived during the visit.

At 9:28 AM, LPA toured the facility with Caregiver Mary Melchor. Facility has 6 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing signs are posted throughout the facility. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. Facility has completed the mitigation plan. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed ample shaded outside visitation areas. LPA observed a back house with nobody residing in it during today's visit. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19.

LPA consulted with Executive Director Valle regarding the importance of maintaining a thirty day supply of PPE at all times.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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