<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005752
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:19:37 AM


Document Has Been Signed on 07/29/2022 11:19 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 #1FACILITY NUMBER:
306005752
ADMINISTRATOR:VALLE, ALEJANDRAFACILITY TYPE:
740
ADDRESS:1 LONGSTREETTELEPHONE:
(949) 653-0523
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Irma Bughao, house manager
Leslie Curry, caregiver
Michelle Nesbitt, Administrator		TIME COMPLETED:
11:35 AM
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
On 07/29/2022 at 10:15am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Irma Bughao, caregiver after explaining the purpose of the visit. Staff present called Michelle Nesbitt, Administrator to notify her of the visit. Administrator arrived later to assist with the visit.

At approximately 10:55am, LPA accompanied by Administrator toured the inside and outside of the facility. LPA observed a check-in station at the facility's entrance where visitor temperatures are being documented. There are currently six (6) residents in care, two (2) of which are receiving hospice care. Residents are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The four (4) bedrooms include all necessary components. 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 with a functional magnetic lock. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet located in the dining room. Cleaning supplies are secured ina magnetically locked cupboard under the kitchen sink as well as in the locked attached garage where the laundry room is also located. LPA observed the facility has COVID-19 Precautions and all required department postings. Facility has an adequate supply of PPE. An updated Infection Control Plan has been submitted to the Department.

CONTINUED IN FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 #1
FACILITY NUMBER: 306005752
VISIT DATE: 07/29/2022
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
26
27
28
29
30
31
32
CONTINUED FROM LIC809

Staff present is adequately cleared and associated in Guardian. LPA toured the outside of the facility and observed it to be free of obstructions. LPA observes a shaded area with patio furniture used by residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises. All exits are equipped with functioning sound alarm systems to alert staff when doors are opened.

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: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2