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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006051
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:38:11 PM


Document Has Been Signed on 12/01/2022 02:38 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COTTAGES - SEASIDE, THEFACILITY NUMBER:
306006051
ADMINISTRATOR:MCALEER III, JAMESFACILITY TYPE:
740
ADDRESS:1019 CHEYENNE STREETTELEPHONE:
(949) 955-9000
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Jovany HernandezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Cottages- The Seaside to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 1:49pm, LPA Cho was greeted and granted entry by Caregiver Jovany Hernandez. Also present was Caregiver Teresita Malapitan. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a thermometer at the check-in station along with a sign in sheet. The required COVID-19 precautionary signs were posted in the entryway. At 1:51pm, LPA contacted Administrator Alex Valle and left a voice message and began the tour of the physical plant with Caregiver Hernandez. There are a total of seven resident bedrooms and three resident bathrooms. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. The toilets worked properly, showers were free of mold/mildew, grab bars were secure, slip mats were in place, and bathrooms were adequately stocked with hand soaps and paper towels. Hand washing signs were observed in the bathrooms. The hot water temperature in the resident bathrooms measured at 105.6 degrees Fahrenheit in Bathroom #1, 102.3 degrees Fahrenheit in Bathroom #2, and 105.2 degrees Fahrenheit in Bathroom #3. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and serviced on 04/18/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. There was shading and sufficient seating for residents. The exit gates were self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs. LPA checked the second floor which is utilized as an office space for management. No concerns were observed.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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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 - SEASIDE, THE
FACILITY NUMBER: 306006051
VISIT DATE: 12/01/2022
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Based on the observations made during today's visit, no deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. LPA spoke to Admin Kimberly Walters who was with Admin Alex Valle at 2:16pm. Both Admins authorized Caregiver Hernandez to sign the report. An exit interview was conducted with Caregiver Jovany Hernandez, and a copy of this report was provided during this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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