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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006268
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:50:06 PM


Document Has Been Signed on 04/10/2024 04:50 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 #12FACILITY NUMBER:
306006268
ADMINISTRATOR:MEDINA, ALLENFACILITY TYPE:
740
ADDRESS:19462 SIERRA CHULATELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 5DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Facility Administrator - Rochel MalacaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Rochel Malaca. For this visit, there are a total of 5 residents in care.

LPA observed the administrator certificate for Rochel Malaca which expires on 10/5/2024. The PUB475 "See Something, Say Something" poster was observed to be posted at the entrance of the facility. Facility is licensed for 6 non-ambulatory residents, of which 6 may be on hospice.

LPA De Perio toured the interior and exterior portions of the facility with AD Malaca. The facility is a single level structure. There are a total of 6 bedrooms, of which 4 are private resident rooms, 1 shared resident room and 1 staff room. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms in the facility. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 114.1 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.



LPA De Perio observed the emergency disaster and evacuation plan, which is posted in at the entrance. Facility had back-up emergency food and water supply, located in the kitchen and in the garage.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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 #12
FACILITY NUMBER: 306006268
VISIT DATE: 04/10/2024
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LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were observed to be locked and made inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with AD Malaca.

A copy of this report was provided and explained.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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