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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006259
Report Date: 05/08/2024
Date Signed: 05/08/2024 01:00:32 PM


Document Has Been Signed on 05/08/2024 01:00 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:IRVINE COTTAGE #2FACILITY NUMBER:
306006259
ADMINISTRATOR:WALTERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:16 PORTERTELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kimberly ArnettTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Michael Tea and Licensing Program Manager (LPM) Sheila Santos conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 9:30, LPA and LPM were greeted and granted entry into the facility by caregiver, Julita Galima and explained the reason for the visit. Upon entry the caregiver measured LPA and LPM temperature following the Infection Control plan protocol of the facility. Facility is licensed for 6 non-ambulatory residents and has 5 residents, of which two are on hospice during today's visit. The Administrator, Kimberly Arnett has an Administrator Certificate expiring on 07/21/2024. Administrators Kimberly Arnett and Michelle Nesbitt, Executive Administrator Jozef Springer, and Licensee Angela Kutnerian arrived shortly after to assist during the visit.

LPA Tea, LPM Santos along with the Administrator toured the facility at 9:46 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, 1 staff bedroom, 2 resident bathrooms, living room, dining room, and kitchen. At 10:00AM LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 114.8 F degrees and 116.2 degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA and LPM observed a locked storage area for cleaning supplies underneath the kitchen sink. LPA and LPM observed secured medications in a cabinet. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating and the exit gate is self latching and operational. LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan during the visit, last fire drill was conducted March 01, 2024, quarterly. Plan is thorough and complete. Facility provides activities in the form of games, exercise, and art.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRVINE COTTAGE #2
FACILITY NUMBER: 306006259
VISIT DATE: 05/08/2024
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At 10:50 AM, LPA Tea reviewed five resident files and four staff files. Residents files and staff files contained all required documentation. At 11:30 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was read and provided through email to the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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