306006265-3-23-2023-22-AS-LMAZ-CQ87AL-20230323212943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006265
Report Date: 03/23/2023
Date Signed: 03/23/2023 09:31:00 PM

Document Has Been Signed on 03/23/2023 09:31 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 #10		FACILITY NUMBER:	306006265
ADMINISTRATOR:	NESBITT, MICHELLE		FACILITY TYPE:	740
ADDRESS:	24172 VIA LUISA		TELEPHONE:	(949) 533-5938
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 0	DATE:	03/23/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Michelle Nesbitt		TIME COMPLETED:	12:45 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 Analyst (LPA) Lydia Martinez made an announced visit to the facility for purpose of conducting a Pre-Licensing inspection. LPA arrived at the facility and met with designated Administrator (AD) Michelle Nesbitt. An initial application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of (6) non-Ambulatory was received by CCL on 11/15/2022. Structure: The facility is a one story home with 7 bedrooms, six bathrooms, living room, kitchen, dining room, 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 dining room area. There is a back yard with an exit gate on each side of the house. There is a patio table and chairs with umbrella for shade. LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms: have the required furnishings. LPA observed all Resident beds have linens and blankets. Bedroom Staff: There is one staff room. Bathrooms: have designated hand washing posters, toilet paper and paper towels. Hot water in bathrooms is within regulatory requirements. Signal system: Call buttons will be used. Toxins: All and any toxic chemicals, cleaning solutions, laundry soap, and disinfectants will be made inaccessible to the Residents. Toxins will be stored in locked garage and under locked kitchen sink . Linens & Hygiene Supplies: Supply of extra linen are stored in a hallway closet. Emergency Phone Numbers, Exit Plan & Menu: will be posted and available for review along with Emergency Disaster Plan with means of exiting and Emergency phone numbers list. Menu will be posted and visible. Food Service: AD acknowledged facility will have a supply of 2-day perishable and 7-day of non-perishable food on hand when Residents are present. Smoke Detectors: Smoke detectors and Carbon Monoxide detectors are centrally wired and operational. Appliances: Gas stove with oven, refrigerator, microwave, washer, and dryer are operational. (cont lic809c)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 #10	FACILITY NUMBER: 306006265
	VISIT DATE: 03/23/2023

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Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet near dining area. First Aid Kit is located by medication cabinet and has all the required elements. Resident & Staff Files: will be stored in locked medication cabinet. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: Fire Extinguishers are fully charged and mounted. Reading Material, Games, Activity Equipment & Materials: The facility has board games, puzzles, and TV exercising. Fire clearance: Was cleared on 01/12/2023. Component III: Component III was waived during visit, as designated AD is Administrator of other licensed facilities.

Designated AD/Applicant was reminded that it is required to notify LPA, within 5 business days of admitting first Resident. This notification may be done by phone, email or fax.

The AD was notified the Pre-Licensing is complete and this facility has no deficiencies. All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to the email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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