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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006155
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:02:53 AM

Document Has Been Signed on 07/16/2024 11:02 AM - 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 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: 28DATE:
07/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:16 AM
MET WITH:Aurelia OlaisTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with Complaint #22-AS-20240711133659. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA toured the facility and reviewed medications as well as reviewed file for Resident 1 (R1). Audit of three of R1's medications showed that medications on hand do not match start date of medication bottles and Medication Administration Record is missing multiple staff initials for May, June and July 2024. Information obtained during complaint investigation indicated R1 had a half bed rail during the time of complaint incident. Facility does not have an order for half bed rails in resident file.




Based on the visit conducted, deficiencies are 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 07/16/2024 11:02 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/16/2024 at 10:29 AM
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: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2024
Section Cited
CCR
87464(f)(1)

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to provide medication retraining to staff and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure care was being provided to R1. Medication audit revealed medications are not being administered per physician order. This poses an immediate health and safety risk to residents in care.
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Type B
07/30/2024
Section Cited
CCR87608(a)(3)

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Based on the individual's preadmission appraisal.. Postural supports may be used under the following condition: A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This req is not being met as evidenced by:
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Licensee to provide a statement of understanding of the regulation and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure there is a written physician order for half rails for R1. This poses a potential health and safety risk to residents 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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