306005751-4-29-2020-22-AS-AMSR-BP3SDV-20200427134747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005751
Report Date: 04/27/2020
Date Signed: 04/29/2020 04:04:29 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 #3		FACILITY NUMBER:	306005751
ADMINISTRATOR:	WALTERS, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	17 YORKTOWN STREET		TELEPHONE:	(949) 653-2213
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY:	6	CENSUS: 5	DATE:	04/27/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Kimberly Walters - Administrator Rachel Dupont - General Manager		TIME COMPLETED:	01:50 PM

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Licensing Program Analyst (LPA) Ann Marie Slotemaker conducted an announced Pre-Licensing visit via phone FaceTime virtual technology to Irvine Cottage #3 due to the Coronavirus Pandemic and precautionary measures. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on January 2, 2020 for a capacity of 6 non-ambulatory residents.

LPA Slotemaker observed and toured the following areas.

Structure:
Facility is a one story house with 4 resident bedrooms, 1 staff bedroom, 2.5 bathrooms, living room, dining area, and kitchen. The facility has a yellow wood siding exterior with white trim. There is an attached 2 car garage and the house has a washer and dryer located in the garage. The backyard has a shaded concrete area with seating for 6 residents as well as a small grassy area in the front of the facility with seating.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in a hallway. If indicated each resident will be equipped with a call button to summon staff when they need assistance. The facility utilizes video surveillance cameras in the common area.
Bedrooms Residents:
All bedrooms accommodate non-ambulatory residents. Emergency lighting is present in each bedroom as well as in the hallways and living room. The resident bedrooms accommodate residents' furnishings with all required furniture present.
Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars were present as a well as a non-skid mat.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Ann Marie Slotemaker	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2020

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 #3	FACILITY NUMBER: 306005751
	VISIT DATE: 04/27/2020

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Linens and Hygiene Supplies:
Adequate supply of linens is stored in the hallway closet. Hygiene supplies are stored in a locked cabinet in each resident bathroom with extra hygiene supplies stored in the garage.
Emergency Phone Numbers, Exit Plan:
Readily available for review in the hallway.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was posted on the refrigerator as well as in a binder containing sample menus with recipes. Additional food and emergency supplies are stored in a cabinet as well as in bins located in the garage.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems are hardwired were tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen. There is 1 additional fire extinguishers on a wall inside of the garage.
Fire Clearance:
Approved on 3/3/2020.
Appliances:
Gas four burner stove, single oven, dishwasher, microwave, and a refrigerator/freezer. A second refrigerator/freezer is located in the garage. The washer and dryer are located in the garage and noted to be operational.
Toxins and Sharps:
Locked and stored in a locked cabinet located in the garage. The knives are stored in a locked kitchen drawer.
Water Temperature:
Tested and recorded at 112 degrees Fahrenheit in bathroom 1 and at 109 degrees Fahrenheit in bathroom 2 and at 113 degrees Fahrenheit in bathroom 3
Medications, First Aid Kit & Manual:
First Aid kit with manual is stored in a locked kitchen cabinet. Medication is stored in a locked cabinet located in the kitchen.
Resident and Staff Files:
Records will be kept in a separate cabinet located in the kitchen.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Ann Marie Slotemaker	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2020

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 #3	FACILITY NUMBER: 306005751
	VISIT DATE: 04/27/2020

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Reading Material, Games, Equipment, & Materials:
The facility has activities that commensurate with their plan of operation.

Component III:
The Component III orientation was conducted for this Pre-Licensing visit as Administrator Kimberly Walters along with General Manager Rachel Dupont participated in the orientation.

All of the items reviewed during this visit are in compliance. Facility appears ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit phone interview was conducted with Kimberly Walters and General Manager Rachel Dupont and a copy of this report was signed by LPA Slotemaker. This report will be sent via email to Administrator Kimberly Walters who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Kimberly Walters agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Ann Marie Slotemaker	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2020

LIC809 (FAS) - (06/04)

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