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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006054
Report Date: 11/10/2021
Date Signed: 11/10/2021 05:05:01 PM

Document Has Been Signed on 11/10/2021 05:05 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:PAGEANTRY COTTAGE, THEFACILITY NUMBER:
306006054
ADMINISTRATOR:JABONERO, MACRINAFACILITY TYPE:
740
ADDRESS:125 PAGEANTRY DRTELEPHONE:
(714) 504-5371
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 0DATE:
11/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Macrina JaboneraTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted this announced inspection for the purpose of conducting a Pre-licensing inspection. LPA met with licensee Edna Tamondong and Administrator (AD) Macrina Jabonero discussed the purpose of the inspection, and toured the facility. Facility is to operate is to operate as a Residential Care Facility for the Elderly (RCFE).

At 2:30PM, LPA and AD toured the facility and observed the following. This is a one-story home with 8-bedrooms, 5-bathrooms, and a garage. Five of the bedrooms will be used for residents, 2 bedrooms for staff, and one bedroom will be used as an office. LPA observed a gated pool in the backyard which was locked . LPA observed clean bedrooms and beds which had clean linen. The restrooms had soap and paper towels. LPA observed walkways free from obstruction. The water temperature for each bathroom tested between 109.5 and 116.4 F degrees. LPA observed knives that were locked. LPA observed a locked area where medication will be stored. LPA reviewed fire clearance, operations plan, and emergency plan. Facility did not have 2-day supply of perishables but did have 7-day nonperishable food supply. LPA observed functioning Carbon Monoxide, Smoke Detectors, and a Fire Extinguishers. LPA observed appliances including a stove, microwave, and refrigerator, washer, and dryer. LPA observed First-Aid Kit & Activity Supplies. Fire clearance was approved by the Placentia Fire Department on September 15, 2021. Backyard exit gate is operational and unlocked. Facility telephone number is (714)646-9848 and email is samednatam@yahoo.com.

LPA answered questions regarding licensing and completed COMP III with AD.

LPA informed AD that facility will be recommended for licensure. An exit interview was conducted, and AD was provided with a copy of this report.

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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