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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005752
Report Date: 04/28/2021
Date Signed: 04/28/2021 01:51:17 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 #1FACILITY NUMBER:
306005752
ADMINISTRATOR:VALLE, ALEJANDRAFACILITY TYPE:
740
ADDRESS:1 LONGSTREETTELEPHONE:
(949) 653-0523
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
04/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Administrator Alejandra "Alex" ValleTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Albert Marin and Kimberly Lyman made an unannounced visit to this facility. LPAs met with Administrator Alejandra “Alex” Valle stated the purpose of this visit, which was to continue the case management for an incident that was initiated last November 11, 2020.

LPAs observed five residents in care and two care staff members on the duty. LPAs also observed the placement of the video surveillance camera in but not limited to living room, dining room and hallways. LPAs interviewed facility staff members.

At the end of the visit, no citation had been issued at this time.

LPAs Marin and Lyman conducted an exit interview with Administrator Valle. Copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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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