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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005750
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:56:00 AM


Document Has Been Signed on 08/16/2022 11:56 AM - 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 #7FACILITY NUMBER:
306005750
ADMINISTRATOR:NESBITT, MICHELLEFACILITY TYPE:
740
ADDRESS:26722 PEPITATELEPHONE:
(949) 581-7691
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Nestor Dayao, caregiver
Julita Galima, caregiver		TIME COMPLETED:
12:15 PM
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On 08/16/2022 at 10:50am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by caregivers Nestor Dayao and Julita Galima after explaining the purpose of the visit and being temperature checked.

At approximately 11:05am, LPA accompanied by caregiver toured the physical plant of the facility. LPA observed a check-in station where visitor temperatures are being documented. There are currently six (6) residents in care, none of which are receiving hospice care. The residents are observed relaxing in the common area or in their respective bedrooms and appear clean and well taken care of. The four (4) bedrooms include all necessary components. An ample supply of linen is observed. The bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen drawer secured by a magnetic lock. LPA observed a sufficient supply of food and water present. A 30-day supply of medication is centrally stored in a cabinet near the locked garage. Cleaning supplies are located in the locked attached garage as well as in cabinets under kitchen and bathroom sinks, secured with functional magnetic locks. LPA observed the facility has COVID-19 Precautions posters and all required department postings as well as hand-washing signs in the bathrooms. The facility has an adequate supply of PPE. A fire extinguisher is present and charged.

Staff present is correctly cleared and fingerprinted in Guardian. LPA and caregiver toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture is present for the enjoyment of residents and visitors. The perimeter gates are self-latching and can easily be opened in an evacuation. There are no bodies of water of water on the premises.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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 #7
FACILITY NUMBER: 306005750
VISIT DATE: 08/16/2022
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CONTINUED FROM FORM LIC809

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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