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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006271
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:45:06 PM


Document Has Been Signed on 03/20/2024 04:45 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 #8FACILITY NUMBER:
306006271
ADMINISTRATOR:NESBITT, MICHELLEFACILITY TYPE:
740
ADDRESS:20271 ORCHIDTELEPHONE:
(949) 553-5938
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 6DATE:
03/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Carla Miranda-AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 03/20/24. LPA was greeted and allowed entrance into the facility by Administrator (AD) Carla Miranda. LPA explained the reason for the visit.

LPA and AD conducted a toured of the inside and outside of the facility as well as bedroom of Resident 1(R1). LPA reviewed and obtained pertinent documents such as Physician Report (LIC602), Salus Hospice Plan of Care, Admission Agreement and X-ray results for R1.

Incident report dated 03/20/24 states that on 03/11/24 R1 tried to stand up from their recliner by themselves, lost their balance and fell. Per incident report staff checked and assisted R1 back into the chair. Per incident report Hospice was notified and a Hospice Nurse arrived the following day to checked on R1. Incident report states that an x-ray technician came on Friday 03/15/24 and the results showed a dislocated shoulder and right arm. Per incident report the facility is awaiting further instructions from Hospice Agency.

Records reviewed by LPA Ramirez included the Salus Hospice Plan of Care (POC) dated 02/09/24 for R1. Per POC under Focus Areas it states that R1 is under Hospice for Congestive Heart Failure.

During the visit LPA reviewed the Synergy Mobile x-ray results dated 03/15/24 for R1. Per x-ray results under findings it states right shoulder joint with posterior dislocation and posterior aspect of the olecranon with suspicious fracture.


During today's visit LPA interviewed AD Miranda who stated that R1 was prescribed pain medication by Hospice and stated that the pain medication arrived yesterday. Per AD Hospice also prescribed an arm sling for R1 which arrived today.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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 3


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 #8
FACILITY NUMBER: 306006271
VISIT DATE: 03/20/2024
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Even though the facility provided first aid for R1 and the Hospice Nurse did a follow-up visit on 03/12/24, the facility failed to seek immediately medical attention to assess R1 who sustained an unwitnessed fall.

California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.



A Civil Penalty is pending determination, per H&S code 1569.49(e)

An exit interview was conducted with AD Miranda and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/20/2024 04:45 PM - It Cannot Be Edited

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 #8
FACILITY NUMBER: 306006271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
87465(g)

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Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee will provide an in-house training to staff regarding contacting 9-1-1 when there is an imminent threat to a resident's health. Licensee to email proof to LPA by POC due date.
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This requirement is not met as evidence by: The facility failed to seek immediately medical attention to assess R1 who sustained an unwitnessed fall. Facility failed to contact 9-1-1 instead waited approximately 24 hours for Hospice to show up and assess R1’s post fall. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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