306005828-8-21-2024-22-AS-RMRT-D8CTMX-20240821145152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005828
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:52:25 PM

Document Has Been Signed on 08/21/2024 02:52 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	RAE'S COTTAGE AT BREA		FACILITY NUMBER:	306005828
ADMINISTRATOR:	ROCHE, LISA		FACILITY TYPE:	740
ADDRESS:	1306 W ALTA MESA DRIVE		TELEPHONE:	(714) 553-8292
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	6	CENSUS: 6	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Spoke with Lisa Roche, Administrator via phone		TIME COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 10:00am. During today’s visit, LPA spoke with Lisa Roche, Administrator (AD) via telephone. The facility is a single story building with an approved fire clearance of six ambulatory residents of which six may be non-ambulatory and an approved hospice waiver for six. The facility currently has a census of six residents in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperatures in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 107.2 and 119.2 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on May 7, 2024. The facility’s last fire drill was conducted on August 2, 2023. Residents were observed watching a movie during facility tour with Staff #2 (S2). All sharps, medications and detergents were secured. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. The first aid kit is complete with additional manuals. Per review medications are being given as prescribed. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. Staff training was reviewed and two staff members will continue to take educational courses. (See LIC 809-C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RAE'S COTTAGE AT BREA	FACILITY NUMBER: 306005828
	VISIT DATE: 08/21/2024

NARRATIVE

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(Continuation from LIC 809)

LPA confirmed that administrator has an administrator certificate which expired on July 15, 2024 but is currently on the pending renewal list.

Technical Violations will be given for the following: Resident #2 (R2) does not have bed rail orders on file. Hospice agency has been contacted by staff and R2 recently transitioned to hospice services. Medical assessments for Residents #3, #4 and #6 need to be updated due to diagnosis. And an emergency disaster drill must be conducted quarterly. LPA spoke with AD Roche via phone regarding the above.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with S1 and S2, and verbally shared with AD Roche, and a copy of the report, LIC 9102-TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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