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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006155
Report Date: 12/09/2022
Date Signed: 12/20/2022 08:20:20 AM

Document Has Been Signed on 12/20/2022 08:20 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:OLAIS, AURELIAFACILITY TYPE:
740
ADDRESS:8792 CERRITOS AVENUETELEPHONE:
(657) 256-1063
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 38CENSUS: 24DATE:
12/09/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Facility Administrator-Aurelia OlaisTIME COMPLETED:
12:26 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required post-licensing inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, As of 12/9/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was observed at the entrance of the facility. LPA De Perio observed the Administrator's Certificate for Aurelia Olais, which expired on 11/22/22, however provided documentation to LPA De Perio that renewal application was submitted on 9/25/22, and renewal payment was submitted on 9/26/22.

LPA De Perio toured the interior and exterior portions of the facility with staff on duty (S1). The facility is a two level structure, however, facility is only licensed to utilize the first floor. Facility is licensed for 38 residents 60 years and over, of which 16 may be on hospice and 16 may be bedridden. Also, facility has not been approved to have delayed egress or secure locked perimeters.

Currently, there are a total census of 24 residents in care of which 6 are on hospice. Bedrooms observed were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Most recent fire inspection took place on 7/13/22 of which was passed. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Facility has a total of 19 shared bedrooms of which all have 1 shared bathroom. Water temperature in restrooms were measured at 105.4 degrees Fahrenheit. LPA De Perio also tested pull cords in random resident bathrooms, and observed it was operational.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 12/09/2022
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Fire extinguishers were charged, mounted and located in the facility hallway.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the supply closet.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE. Medications were locked in the medication room. Toxins were also observed to be locked and inaccessible to residents in care and located in the laundry room.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Olias. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio advised AD Olias to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Olias and a copy of this report was provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
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Document Has Been Signed on 12/20/2022 08:20 AM - It Cannot Be Edited


Created By: Celine DePerio On 12/09/2022 at 11:21 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: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1) Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, licensee did not comply with the section cited above to lock other items that could constitute a danger to the resident(s) which could post a danger. LPA observed, boxes of needles in a bag next to the resident’s bed. Staff on duty removed bag of needles and placed it in the medication room. Threat reduced. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
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As plan of correction, facility will provide training to staff regarding regulation cited and will provide proof to Community Care Licensing and assigned LPA on or by 12/23/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Luz Adams
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


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