306006268-3-30-2023-22-AS-RMAZ-CQESJP-20230330135529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006268
Report Date: 03/30/2023
Date Signed: 03/30/2023 01:56:09 PM

Document Has Been Signed on 03/30/2023 01:56 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IRVINE COTTAGE #12		FACILITY NUMBER:	306006268
ADMINISTRATOR:	NESBITT, MICHELLE		FACILITY TYPE:	740
ADDRESS:	19462 SIERRA CHULA		TELEPHONE:	(949) 533-5938
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Michelle Nesbitt		TIME COMPLETED:	02:30 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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry by Michelle Nesbitt, Administrator. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was submitted to CCL on 11/15/22. Structure: The facility is a one story house with an attached garage with five resident bedrooms, two full bathrooms, 1 half bathroom, one staff brake room, a living room, a dining room, a courtyard, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a backyard with one exit way on the side of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms accommodate six nonambulatory residents with four private bedrooms and one shared bedroom accommodating two residents. Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRVINE COTTAGE #12	FACILITY NUMBER: 306006268
	VISIT DATE: 03/30/2023

NARRATIVE

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Bedrooms Staff:
No bedroom designated for awake-staff. Facility has a staff break room with a half bathroom.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway cabinet space.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of seven-day non-perishable and two-day perishables are stored in the kitchen with surplus goods stored in garage.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Facility has three charged fire extinguishers located in garage, bedroom hallway and outside of staff break room dated 04/18/22.

Appliances:
Electric four-burner stove, single oven, two refrigerator (one refrigerator located in garage), dishwasher, microwave, washer, and dryer are clean and noted to be operational.

Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRVINE COTTAGE #12	FACILITY NUMBER: 306006268
	VISIT DATE: 03/30/2023

NARRATIVE

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Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and garage storage cabinet.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 109.4 Fahrenheit degrees in resident bathrooms.

Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet in kitchen. Additional first aid kits on wall throughout the facility.

Resident & Staff Files:
Records will be kept locked cabinet space located kitchen.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Fire clearance:
Was approved on 12/16/22.

Component III:
Component III waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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