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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006155
Report Date: 06/18/2024
Date Signed: 06/18/2024 04:51:30 PM

Document Has Been Signed on 06/18/2024 04:51 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COTTAGES AT ARTESIA ANAHEIM, THEFACILITY NUMBER:
306006155
ADMINISTRATOR/
DIRECTOR:		OLAIS, AURELIAFACILITY TYPE:
740
ADDRESS:8792 CERRITOS AVENUETELEPHONE:
(657) 256-1063
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 38CENSUS: 31DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Aurelia Olais, Administrator and Pam Bracamonte, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Business Office Manager (BOM) Pam Bracamonte. LPA met with BOM and Administrator (AD) Aurelia Olais.

The facility is a one-story building with nineteen resident bedrooms with access to shared bathrooms, dining room, kitchen, medication room, staff office, laundry room and courtyard. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The courtyard has shaded seating areas. Water temperature measured between 105 and 120 F degrees in resident bathrooms.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted throughout the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke alarm and sprinkler system was serviced in November of 2023. LPA initially observed the signal system console to be unplugged. A deficiency is being issued. LPA instructed staff to plug it back in. While inspecting the kitchen, LPA observed a tray of desserts in the refrigerator uncovered. A deficiency is being issued. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked. LPA reviewed four resident medications, four resident files and four staff files. LPA conducted resident and staff interviews.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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Document Has Been Signed on 06/18/2024 04:51 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 06/18/2024 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COTTAGES AT ARTESIA ANAHEIM, THE
FACILITY NUMBER: 306006155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(B)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to the signal system console not being plugged in at the time of inspection which posed a potential safety risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator stated they will conduct a training with staff to ensure they check the signal system console to ensure it is plugged in and operable. AD stated that, by the assigned POC due date of 7/2/2024, they will email LPA documentation indicating what staff attended the training and what information was covered.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to a tray of desserts being uncovered in the refrigerator at the time of inspection which poses a potential health risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator stated they will conduct a training with kitchen staff to ensure they keep food covered until it is time to serve it. AD stated that, by the assigned POC due date of 7/2/2024, they will email LPA documentation indicating what staff attended the training and what information was covered.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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