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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006270
Report Date: 03/27/2023
Date Signed: 03/27/2023 05:09:33 PM


Document Has Been Signed on 03/27/2023 05:09 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 #7FACILITY NUMBER:
306006270
ADMINISTRATOR:NESBITT, MICHELLEFACILITY TYPE:
740
ADDRESS:40 CYPRESS TREE LANETELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 6DATE:
03/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Michelle NesbittTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted this announced visit for the purpose of conducting a Pre-Licensing inspection. LPA Martinez met with Applicant (AP) Michelle Nesbitt and a tour of the inside and outside of the facility was completed.
Facility is to operate a Residential Care Facility for the Elderly (RCFE). The Application was submitted to Community Care Licensing on 11/15/2022. Facility is an existing facility and undergoing a Change of Ownership. There are 6 Residents in care under the current license. Facility is a one story, 6 bedroom, 3 bathroom home with an attached garage. Facility will have live-in staff. A Fire Clearance was granted for 6 non-Ambulatory Residents on 12/16/2022. Facility is secured by a fence around the property. Adequate seating is available in the dining room as well as the living room. One bedroom is double occupancy and all are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms have wash basin and walk in showers. Linen supply is ample supply for residents. Facility has a current food supply of two day perishables and seven day non-perishables. Smoke detectors are centrally wired and are operational. Carbon Monoxide was operational. Fire extinguishers are mounted and charged. Stove, oven, refrigerator, dishwasher, microwave, washer, and dryer are clean and operational. Toxins were locked/stored in the garage and under locked cabinet under kitchen sink. Hot water in bathroom was tested and is within regulatory requirements. First Aid Kit observed contained all required items. Medication is stored in the locked cabinet in the kitchen. The facility has activity supplies such as puzzles, TV exercise, coloring, paint and bingo. Facility has a patio table and chairs with a large canopy for shade. Side exit gate is unlocked and self latching. The Component III was waived as Applicant is an existing Administrator for other existing facilities and also completed the Component III on 3/20/2023 with LPA Sean Haddad.
There is a discrepancy with the floor plan approved by the Fire Department with staff/storage room. LPA spoke to Fire Inspector and is awaiting for a response. LPA explained to AP that clarification from Fire Inspector is needed before the facility can be ready for licensure based on inspection. LPA to contact AP once LPA hears back from Fire Inspector. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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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