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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006260
Report Date: 04/12/2023
Date Signed: 04/12/2023 09:21:54 AM


Document Has Been Signed on 04/12/2023 09:21 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:IRVINE COTTAGE #1FACILITY NUMBER:
306006260
ADMINISTRATOR:WALTERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:1 LONGSTREETTELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 0DATE:
04/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michelle NesbittTIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection to follow up on corrections identified during visit on 03/29/2023. LPA arrived at the facility and was greeted and granted entry by 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 residents was received by CCL on 11/15/2022.

At 9:05 a.m. LPA toured the facility and observed the following:

· Cameras in four out of four resident bedrooms have been removed.

· Decorative fence in front of fireplace has been replaced with a fireplace screen.

All noted items from visit on 3/29/2023 have been addressed. LPA provided CM a copy of surveillance camera guidelines.

An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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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