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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005757
Report Date: 02/16/2023
Date Signed: 02/16/2023 05:42:27 PM


Document Has Been Signed on 02/16/2023 05:42 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: 0DATE:
02/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Michelle Nesbitt, AdministratorTIME COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit at the facility for the purpose of confirming the fact that no residents are currently occupying the facility as notified on January 30, 2023 by licensee George Kutnerian.

LPA arrived at the facility and rang the doorbell, which was not answered. An alarm was heard sounding inside the physical plant. LPA left a voicemail to Michelle Nesbitt, administrator and spoke to Kim Walters, administrator.

Administrators arrived shortly afterwards to assist with the visit.

LPA and administrators conducted a tour of the physical plant which confirmed that no residents are currently admitted to the facility. A full remodel will be scheduled, however administrators may conduct the pre-licensing visit for change of ownership before initiating work.

An exit interview was conducted and a copy of this report was provided and left with facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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