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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005750
Report Date: 09/23/2021
Date Signed: 09/23/2021 10:45:14 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 #7FACILITY NUMBER:
306005750
ADMINISTRATOR:NESBITT, MICHELLEFACILITY TYPE:
740
ADDRESS:26722 PEPITATELEPHONE:
(949) 581-7691
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
09/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Michelle Nesbitt TIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPAs) Norman Woodridge and Albert Marin conducted an unannounced visit to the facility to conduct a case management visit and to review Coronavirus 2019 (COVID-19) mitigation plan. Caregivers, Julita Galima (S1) and Nestor Galima (S2) greeted LPAs. LPAs stated the purpose of the visit, was granted LPAS entry into the building, and went through screening procedure upon entering the building.

LPAs conducted a tour of the inside and outside of the facility. LPAs observed 6 residents and 2 staff members on the floor. LPAs met with administrator, Michelle Nesbitt, and discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19). LPAs discussed Covid-19 Mitigation Plan with administrator and provided administrator with a copy of the facility’s approved Mitigation Plan.

No deficiencies were observed, and citations were not issued.

LPAs Norman Woodridge and Albert Marin conducted an exit interview with administrator and provided her with copies of this report and PIN 21-38-ASC.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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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