306006259-3-29-2023-22-AS-CGUZ-CQDUDC-20230329152920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006259
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:29:25 PM

Document Has Been Signed on 03/29/2023 03:29 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IRVINE COTTAGE #2		FACILITY NUMBER:	306006259
ADMINISTRATOR:	WALTERS, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	16 PORTER		TELEPHONE:	(949) 533-5938
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY: 6		CENSUS: 5	DATE:	03/29/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Michelle Nesbitt		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs met with Compliance Manager (CM) Michelle Nesbitt. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by CCL on 11/15/2022. Structure: The facility is a one-story house with five resident bedrooms, two bathrooms, living room, kitchen, dining room, staff bedroom, and an attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with one exit gate on the side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked beneath the kitchen sink. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 12/16/2022. No special conditions noted.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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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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: IRVINE COTTAGE #2	FACILITY NUMBER: 306006259
	VISIT DATE: 03/29/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is mounted on the wall in the dining room area and stored in a kitchen cabinet as well. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the dining room area.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has coloring books, bingo, and other toys that will be kept in the living room area.

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

Bedrooms Staff:

One bedroom will be occupied by staff.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 107.6 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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: IRVINE COTTAGE #2	FACILITY NUMBER: 306006259
	VISIT DATE: 03/29/2023

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

CM was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to CM.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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