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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005757
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:37:38 PM


Document Has Been Signed on 12/20/2022 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:IRVINE COTTAGE #11FACILITY NUMBER:
306005757
ADMINISTRATOR:NESBIT, MICHELLEFACILITY TYPE:
740
ADDRESS:24172 VIA LUISATELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
12/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michelle Nesbitt, Compliance Manager
Kim Walters, Administrator		TIME COMPLETED:
04:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit for the purpose of citing deficiencies observed while at the facility. LPA was greeted and granted entry by caregiving staff who notified administrators Michelle Nesbitt and Kim Walters, who arrived shortly afterward to assist with the visit.

While reviewing the facility's staff log, LPA observed three dated instances of fall incidents for resident R1. The fall incidents occurred on 09/30/2022, 12/03/2022, 12/10/2022. In all instances, 911 was called and paramedics dispatched to the facility. Fall resulted in a transfer to the hospital for evaluation on 09/30/2022. LPA reviewed the Special Incident Reports transmitted to the Department over the same time period and was unable to locate any report. Facility is noted to have failed to report these multiple incidents as required by Title 22 Regulations.

Additionally, resident R1 was transferred from a different facility managed by the same licensee, but no update to the initial agreement are observed to have been made upon admission into the current facility. A Technical Violation note is being issued in that regard.

LPA also observed a non-functional doorbell. This item is noted in a Technical Advisory note issued during the visit.

Based on the observations and records reviewed today, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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Document Has Been Signed on 12/20/2022 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: IRVINE COTTAGE #11
FACILITY NUMBER: 306005757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2023
Section Cited

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The California Code of Regulations Section 80061 on Reporting Requirements states that "Upon the occurrence (...) of any of the events specified (....) below, a report shall be made to the licensing agency. Events reported shall include the following: Any injury to any client which requires medical treatment.
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Licensee and administrator will review the cited regulations and ensure that an adequate reporting process is in place for any future incidents.
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Any unusual incident or client absence which threatens the physical or emotional health or safety of any client." This requirement is not met as evidenced by unreported incidents on 04/01/22 and 11/24/22. This failure to report poses a potential risk to the health and safety of the persons in charge.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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