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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005757
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:08:12 PM


Document Has Been Signed on 03/22/2023 04:08 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:
03/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michelle Nesbitt, AdministratorTIME COMPLETED:
01:59 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit for the purpose of delivering findings in the complaint #22-AS-20221216140129 and issuing consultations on two compliance items detailed below.

The facility is currently vacant. LPA notified administrator Kim Walters of the visit via telephone. Administrator Michelle Nesbitt arrived later in person to assist with the visit.

Over the course of the investigation of complaint #22-AS-20221216140129, it was determined that resident R1 suffered a fall on January 6, 2023. The fall was stated to incur a mild skin tear injury to the forehead. In the absence of ay signs of a major injury, staff and family opted to not transfer the resident to the hospital due to no immediate medical care being required. A Technical Assistance Advisory note is being issued in regard to Reporting Requirements during the visit.

A Technical Assistance Advisory Note is additionally issued in regard to the night supervision staffing requirements regarding residents diagnosed with dementia.

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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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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