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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006155
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:32:12 AM

Document Has Been Signed on 01/19/2023 11:32 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: 21DATE:
01/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Facility Administrator-Aurelia OlaisTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced case management visit to this facility to follow up on a Special Incident Report (SIR) received on 12/27/22, which occurred on 12/16/22. LPA De Perio was greeted and granted entry by staff on duty and LPA De Perio explained reason for visit.

For today's visit, there are a total of 21 residents in care, of which 5 are on hospice. As of today, there are no active COVID cases in the facility as verified.

LPA De Perio met with staff 1 (S1),staff 2 (S2) and facility administrator (AD) Aurelia Olais and conducted interviews regarding resident identified in SIR. S1, S2 and AD Olais stated that the incident reported via SIR happens "all the time".

LPA De Perio conducted a tour of the resident's room and interviewed resident. LPA De Perio also reviewed and obtained copies of pertinent documents.

At this time, no citations have been issued and no deficiencies have been issued.

LPA De Perio conducted an exit interview with AD Olais and a copy of this report was provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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