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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005749
Report Date: 07/19/2022
Date Signed: 07/19/2022 12:44:00 PM


Document Has Been Signed on 07/19/2022 12:44 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 #9FACILITY NUMBER:
306005749
ADMINISTRATOR:MCALEER III, JAMESFACILITY TYPE:
740
ADDRESS:20271 ORCHIDTELEPHONE:
(949) 533-5938
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 6DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Michelle NesbittTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Irvine Cottage #9. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. At 11:43 am, LPA Cho was allowed entry into the facility and met with Caregiver (CG) Liz Hernandez after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregivers Norberta Cantu and Rex Deltran were also present. Caregivers Hernandez and Deltran are agency staff from Stat Home Care. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility is licensed for six non-ambulatory residents. The facility also has a Hospice waiver for three residents. There are currently six residents living in the facility of which two are in hospice care.

At 11:50 am, LPA Cho conducted a tour of the physical plant along with CG Hernandez. At 11:54 am, Compliance Manager (CM) Michelle Nesbitt arrived at the facility to assist with the tour. The two story home consists of five resident bedrooms and bathrooms. There is one locked staff private room and bathroom on the second floor. The facility also has a living room, dining area, and kitchen. The six residents in the facility appeared well-groomed and well cared-for. LPA Cho observed the Complaint Poster in the correct size. 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 including paper towels and hand soaps. The required hand washing signs were observed in all five bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 107.2 degrees Fahrenheit in Bathroom #1, 106.1 degrees Fahrenheit in Bathroom #2, 107.9 degrees Fahrenheit in Bathroom #3, 112.8 degrees Fahrenheit in Bathroom #4, and 107.6 degrees Fahrenheit in Bathroom #5.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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 2


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 #9
FACILITY NUMBER: 306005749
VISIT DATE: 07/19/2022
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LPA Cho inspected the kitchen along with CG Hernandez. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The two fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested along with CM Nesbitt 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 Cho along with CM Nesbitt toured the outside grounds. There were no bodies of water present. LPA observed a locked Accessory Dwelling Unit (ADU) in the backyard that is currently being used as storage. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the side gates were self-closing and self-latching. There were no security bars or weapons on the premises.

LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply stored in the garage. The First Aid Kit had all the required components, and the facility had sufficient PPEs.


No resident or staff files were reviewed at the time of this visit. LPA reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. Two facility tablets are provided to residents upon request.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Compliance Manager Michelle Nesbitt, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2