306005999-12-17-2021-22-AS-KLYN-C9SRPW-20211217121238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005999
Report Date: 12/17/2021
Date Signed: 12/17/2021 03:53:47 PM

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:	COTTAGES AT ARTESIA, THE		FACILITY NUMBER:	306005999
ADMINISTRATOR:	HASSAN, DILUVAN		FACILITY TYPE:	740
ADDRESS:	6041 KINGMAN AVENUE		TELEPHONE:	(800) 570-2273
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY:	55	CENSUS: 38	DATE:	12/17/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Aurelia Olais and Dillon Hassan		TIME COMPLETED:	12:32 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 Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch made an announced visit to conduct a pre-licensing inspection. LPAs identified themselves and discussed the purpose of the visit with Administrator Aurelia Olais. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 04/09/2021 for a capacity of fifty five non-ambulatory residents. Administrator Aurelia Olais has an administrator certificate expiring on 11/22/2022. Licensee Dillon Hassan arrived during the visit. LPAs Lyman and Saborit-Guasch along with Administrator Olais toured the facility at 9:30 AM and observed the following: Structure: Facility is a one story, two building facility with a tan exterior. The exit gate is closed and equipped with delayed egress. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms are a mix of single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has designated shower rooms for residents. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Available for review in the entrance area of the facility. Food Service: Facility has ample 2 day perishables as well as 7 day non-perishables in the pantry. Facility provided proof of daily temps on refrigerators and freezers. Smoke Detectors: Smoke detectors are centrally wired and tested by an outside agency. Carbon Monoxide detectors tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Secured in various locations.. Water Temperature: Tested and recorded between 105 and 120 degrees F. in facility bathrooms. Emergency Supplies: LPAs observed ample emergency food and water as well as thirty day supply of PPE, soap and sanitizer. CONTINUED ON LIC 809C DATED 12/17/2021

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COTTAGES AT ARTESIA, THE	FACILITY NUMBER: 306005999
	VISIT DATE: 12/17/2021

NARRATIVE

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Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed completed emergency disaster plan. Medication is be stored and locked in medication cart. Facility uses an electronic medication administration record. Resident & Staff File: Records are stored in facility office. Reading Material, Games, and Equipment: Facility has ample activities including exercise, games, and movies. LPAs observed residents participating in activities during the visit. Outside Area: LPAs observed a clean outside area with ample shaded seating for residents. Fire Clearance: Approved for 55 non-ambulatory residents on 08/04/2021.

Licensee to address the following and forward proof to LPA by 12/31/2021:

Please remove walkers and wheelchairs from the outside walkway
Please repair/ replace dresser drawers in rooms 11, 16, and 26.
Please clean/ repair discoloration on walls in rooms 7 and 9.
Please install handrails in the hallway of the main building.
Please repair/ replace the cupboard in the sun room shower room.

Component III not conducted during this visit as Licensee has been running the facility prior to the pre-licensing.

The facility is not ready to be licensed. Licensee to notify LPA when corrections are completed.

An exit interview was conducted with Licensee and Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC809 (FAS) - (06/04)

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