306006155-6-13-2022-22-AS-PVEZ-CFCPC2-20220613111114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006155
Report Date: 06/13/2022
Date Signed: 06/13/2022 11:11:21 AM

Document Has Been Signed on 06/13/2022 11:11 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, THE		FACILITY NUMBER:	306006155
ADMINISTRATOR:	OLAIS, AURELIA		FACILITY TYPE:	740
ADDRESS:	8792 CERRITOS AVENUE		TELEPHONE:	(657) 256-1063
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 38		CENSUS: 16	DATE:	06/13/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Aurelia Olais - Administrator Katie Corbeto - Office Manager		TIME COMPLETED:	11:25 AM

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an announced Pre-Licensing visit with Component III Orientation at The Cottages at Artesia Anaheim. LPA Velazquez conducted the visit with Administrator Aurelia Olais and Licensee Diluvan Hassan. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 02/18/2022 for a capacity of 22 non-ambulatory residents and 16 bedridden residents.

LPA Velazquez along with Administrator Olais and Licensee Hassan observed the following:

Structure:
Facility is a one story building with 38 resident bedrooms, 16 bathrooms, dining room which doubles as an activity room, office, medication room, laundry room and kitchen. The facility has a beige stucco exterior. There are 2 courtyards outside with shading and seating for residents.
Signal System:
The facility has a signal system that was tested and found to be in operating condition. Staff responded to the pull cords within 2 minutes of pulling the cords.
Bedrooms Residents :
All bedrooms accommodate non-ambulatory residents with bedrooms 111, 112, 114, 115, 116, 117, 118, and 119 designated for bedridden residents. Emergency lighting were present in the facility. The resident bedrooms accommodate the residents' furnishings but some rooms were missing chairs and lamps.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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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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 AT ARTESIA ANAHEIM, THE	FACILITY NUMBER: 306006155
	VISIT DATE: 06/13/2022

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Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars were secure and a non-skid mat was in place.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were located in a linen cabinet in a hallway as well as the resident rooms.
Appliances: Refrigerator, freezer, dishwasher, 2 washers and 2 dryers, microwave, gas stove top, and an oven.
Emergency Phone Numbers, Exit Plan:
Posted in the entry area of the facility and readily available for review.
Postings:
The Complaint poster was posted in the entry area of the facility. Coronavirus (COVID-19) postings were observed posted throughout the facility.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review. The emergency food supply was located in a supply closet.
Smoke and Carbon Monoxide Detectors:
Smoke detector and Carbon Monoxide alert systems were interconnected tested by the Fire Marshal and found to be operational.
Fire Extinguisher:
Fully charged and were mounted on the walls throughout the facility.
Fire Clearance:
Approved on 05/31/2022 for 22 non-ambulatory residents and 16 bedridden residents. The facility has not been approved to have delayed egress or secure locked perimeters.
Toxins and Sharps:
The cleaning supplies were locked and stored in a storage closet. The knives and other sharp items were locked in a cabinet located in the kitchen.
Water Temperature:
Tested and recorded in 10 resident bathrooms and ranged between 106.6 - 116.6 degrees Fahrenheit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC809 (FAS) - (06/04)

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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 AT ARTESIA ANAHEIM, THE	FACILITY NUMBER: 306006155
	VISIT DATE: 06/13/2022

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Medications, First Aid Kit & Manual:
The facility has 2 First Aid kits which were checked and found to be in order. One First Aid kit is located in the medication room and the other is located in the office. The facility was missing a First Aid manual. Medication is stored in a locked cabinet located in the medication room.

Resident and Staff Files: Resident and staff records are stored in the office.

Reading Material, Games, Equipment, & Materials:

The facility had materials, games, and equipment present in the facility that commensurate with their plan of operation.

Component III:
Conducted at the Pre-Licensing visit, information was provided about how to operate the facility within compliance.

The following items need to be addressed prior to licensure:

Obtain chairs for the resident rooms
Obtain a First Aid manual
Obtain lamps for the resident rooms

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by June 14, 2022. LPA Velazquez will conduct a subsequent Pre-Licensing visit on June 14, 2022 to review the items listed above. An exit interview was conducted with Administrator Aurelia Olais and Licensee Diluvan Hassan a copy of this report was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC809 (FAS) - (06/04)

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