306005750-7-28-2020-22-AS-MBAT-BRXTM5-20200728145033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005750
Report Date: 07/28/2020
Date Signed: 07/28/2020 02:54:27 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 #7		FACILITY NUMBER:	306005750
ADMINISTRATOR:	NESBIT, MICHELL		FACILITY TYPE:	740
ADDRESS:	26722 PEPITA		TELEPHONE:	(949) 581-7691
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	07/28/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	General Manager (GM) Rachel Dupont and Administrator (AD) Michelle		TIME COMPLETED:	12:00 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	At 10:00 AM Licensing Program Analyst (LPA) Mike Barrett contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the announced video call and spoke with General Manager (GM), Rachel Dupont and Administrator (AD), Michelle Nesbit. The facility contains four (5) bedrooms with two (2) full bathrooms, is a single-story building with a 2-car garage. This pre-licensing inspection was due to a change in ownership and the facility had six (6) residents in care at the time of this inspection. The inspection was as follows: Physical Plant: At 10:10 AM LPA Barrett conducted the virtual inspection and toured the inside and outside of this facility with GM Dupont and AD Nesbit, including but not limited to the kitchen, common areas, laundry room, garage, bathrooms, bedrooms, back patio and walkways. LPA observed that the facility was clean, there were no obstructions to the interior or exterior walkways and the backyard gates were observed to be self-closing and self-latching. The kitchen was clean, and knives were stored in a locked drawer. There are smoke/carbon monoxide detectors installed throughout common areas as well as all of the bedrooms which are centrally wired and observed to be in good operation. LPA observed that there were alarms installed on all of the exit doors that were observed to be functional. Fire extinguishers were located in the living room and above the medication cabinet and were observed to be appropriately charged and mounted. Centrally Stored medications were observed to be stored in a locked cabinet that also contained the complete first aid kit . Bedrooms: Bedrooms were observed to have made beds, bedroom furniture, appropriate lighting and exit doors were free of obstructions and exit door alarms were in working order. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

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 #7	FACILITY NUMBER: 306005750
	VISIT DATE: 07/28/2020

NARRATIVE

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Continued from page 1.

Bathrooms:
Bathrooms were equipped with grab bars and non-skid mats in the shower stalls and the water temperatures from the faucets measured within 105 and 120 degrees F.

Supplies:
There was a sufficient supply of toilet paper, paper towels and hand soap, as well as a sufficient stock of linens in the linen closet.

Food Service:
The facility met the 2-day perishable and 7-day nonperishable on hand food supply as LPA observed fresh fruit, canned goods, bread, dairy products, eggs, frozen meats and cereals in both the kitchen and garage. The facility had two (2) refrigerators and cupboards in the kitchen and in the garage. The food was observed to be stored appropriately and away from cleaning supplies.

Records:
Staff and Resident files were kept at the facility and available for review.

Administration:
LPA observed and reviewed the facility’s Emergency Disaster Plan, Resident Personal Rights and “Let-Us-No” poster posted in the facility.

Activities:
The facility had an activities schedule posted with activities staff and volunteers schedules for music, games, arts and crafts and exercises. At the time of the visit, the residents and staff were engaging in exercises and karaoke.

Component III was waived due to GM and AD have already completed the orientation during the recent inspections of other Irvine Cottages. GM and AD stated that the facility does intend to advertise for dementia care.

An exit interview was conducted with General Manager and Administrator and a copy of this report was provided via email and an electronic read receipt confirms the delivery of this report.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

LIC809 (FAS) - (06/04)

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