306006061-12-1-2022-22-AS-JCHO-CLPS8W-20221201123948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006061
Report Date: 12/01/2022
Date Signed: 12/01/2022 12:39:58 PM

Document Has Been Signed on 12/01/2022 12:39 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-WINTERGREEN, THE		FACILITY NUMBER:	306006061
ADMINISTRATOR:	MCALEER, JAMES, III		FACILITY TYPE:	740
ADDRESS:	1565 WINTERGREEN PLACE		TELEPHONE:	(949) 955-9000
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	14	CENSUS: 9	DATE:	12/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kimberly Walters		TIME COMPLETED:	12:50 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) Jessica Cho arrived at Cottages-Wintergreen to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 9:43am, LPA Cho was greeted and granted entry by Caregiver Cecilia Martinez. Also present were Caregivers Leidy Diaz, and Veronica Santana. At 9:49am, LPA spoke to Administrator Alex Valle by a telephone call and designated Licensed Vocational Nurse (LVN) Rosario Prokis to assist LPA with the tour. LVN Prokis arrived at the facility while LPA was on a phone with Admin Valle at 9:51am. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There is one active COVID-19 case as of today. LPA observed Resident 1 (R1) in isolation and confirmed that meals are being delivered to R1's room. Upon entry, LPA observed a thermometer at the check-in station and the required COVID-19 precautionary signs posted in the entry way. There are a total of seven resident bedrooms and four resident bathrooms. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. The 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. LPA did not measure the hot water temperature due to a facility plumbing repair. 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. LPA was unable to test the smoke detectors during the visit. Per Admin and Maintenance Director Brent Deiness, the smoke detectors were an older model and did not have self-testing capabilities. LPA observed all smoke detector lights were blinking in the facility including residents' rooms. Administrator Walters stated that the fire department is scheduled to visit next week and will provide the smoke detector results by Friday, December 9, 2022. 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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 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)

Page: 1 of 3

Document Has Been Signed on 12/01/2022 12:39 PM - It Cannot Be Edited

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-WINTERGREEN, THE	FACILITY NUMBER: 306006061
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review, the facility did not ensure four of four staff were associated to the facility prior to employment which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 12/02/2022
	Plan of Correction
1 2 3 4	Administrator acknowledges and agrees to associate S1 to S4 and to forward proof of correction to LPA Cho by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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-WINTERGREEN, THE	FACILITY NUMBER: 306006061
	VISIT DATE: 12/01/2022

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
26
27
28
29
30
31
32

During the tour with LVN Prokis, Administrator (Admin) Kimberly Walters arrived at the facility approximately 10:31am. The following deficiency was observed and discussed with Admin Walters: Staff 1 (S1) to Staff 4 (S4) were fingerprint cleared but not associated to this facility. LPA reviewed clearance information with Admin Walters for S1-S4 and through the LIS Facility Personnel Report Summary/Guardian.

Based on the observations made during today's visit, a deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An immediate CIVIL PENALTY (LIC421BG) is assessed.

An exit interview was conducted with Administrator Kimberly Walters, and a copy of this report (including LIC809D and LIC421BG) were provided along with the appeal rights.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 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)

Page: 3 of 3