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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006155
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:30:47 PM

Document Has Been Signed on 02/22/2024 01:30 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COTTAGES AT ARTESIA ANAHEIM, THEFACILITY NUMBER:
306006155
ADMINISTRATOR:OLAIS, AURELIAFACILITY TYPE:
740
ADDRESS:8792 CERRITOS AVENUETELEPHONE:
(657) 256-1063
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 38CENSUS: 33DATE:
02/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Aurelia Olais, Administrator
Pamela Brancamonte, Office Manager		TIME COMPLETED:
01:45 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during an initial complaint investigation visit for complaint reference #22-AS-20240213154220.

During a tour of the facility's physical plant, LPA observed the presence of two pairs of scissors in the drawer used to store a resident's colostomy supplies. Facility staff proceeded to remove the scissors during the visit and indicated a lock would be installed on the drawer in question. Type A citation issued and cleared during the visit.

Based on the visit conducted, one deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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 02/22/2024 01:30 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 02/22/2024 at 01:13 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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87705(f)(1)

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Per CCR Section 87705(f)(1) on the Care of Persons with Dementia: "The following shall be stored inaccessible to residents with dementia: (1) Knives, (...), tools and other items that could constitute a danger to the resident(s)". This requirement is not met as evidenced by:
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Facility staff removed the scissors during the visit. Licensee indicates that they will install a lock on the drawer if scissors are to remain stored at that location.
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Based on observations made during the visit, two pairs of scissors are observed to be freely accessible in an unlocked drawer. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
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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
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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