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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006274
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:52:42 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/02/2024 02:52 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:COLOMA COTTAGEFACILITY NUMBER:
306006274
ADMINISTRATOR:SALONGA, MAUREENFACILITY TYPE:
740
ADDRESS:28901 LA LITA LANETELEPHONE:
(949) 218-0672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:6CENSUS: 5DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Anita Sacamay and Audie Baldonasa TIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Rose Ruppert conducted an unannounced visit to Coloma Cottage. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the home and met with Caregiver Anita Sacamay. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 1 resident on hospice during today's visit. Maureen Salonga has an Administrator Certificate expiring on 10/24/2024. Caregiver Baldonasa arrived during the visit.

LPAs along with Caregiver Audie Baldonasa toured the facility at 9:13 AM. LPAs toured the physical plant, checked food service, and the first aid kit. The home consists of four resident bedrooms, one resident bathroom, one shared hall bathroom, living room, dining room, and kitchen. Facility has a strong odor of urine upon entry. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed two residents with half bed rails. Resident bathrooms were checked. At 9:20 AM, LPAs observed unsecured cleaning supplies in the facility bathroom. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 112.6 and 115.5 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and exit gates are unlocked and unsecured. LPAs observed emergency food and water supply in the facility. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of CONT ON LIC 9099C DATED 04/02/2024

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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: COLOMA COTTAGE
FACILITY NUMBER: 306006274
VISIT DATE: 04/02/2024
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last fire drill conducted in 2022. Facility provides activities in the form of games and exercise. At 10:00 AM, LPAs reviewed five resident files and four staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed did not contain required documentation of annual training. Staff 1 is not associated to the facility. At 11:00 AM, LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.


Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/02/2024 02:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: COLOMA COTTAGE
FACILITY NUMBER: 306006274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2024
Section Cited
CCR
87705(f)

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The following shall be stored inaccessible to residents with dementia:
.. and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not being met as evidenced by:
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Licensee to secure all cleaning supplies and toxins and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure cleaning supplies were inaccessible to residents in care. This poses an immediate health and safety risk to residents in care.
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Type A
04/03/2024
Section Cited
CCR87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed faciilty: Request a transfer of a criminal record clearance...
This requirement is not being met as evidenced by:
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Licensee to obtain a transfer of background clearance/ association for Staff 1 and forward proof to LPA.
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Based on record review, Licensee failed to ensure Staff 1 was associated to the facility. 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/02/2024 02:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: COLOMA COTTAGE
FACILITY NUMBER: 306006274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2024
Section Cited
HSC
1565(c)

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 A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter...

This requirement is not met as evidenced by:
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Licensee to conduct an emergency drill and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure emergency drills are conducted. Last documented drill was in 2022. This poses an immediate health and safety risk to residents in care.
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Type B
04/16/2024
Section Cited
CCR87412(c)

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Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by:
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Licensee to conduct training for all staff and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure all staff have required annual training. This poses a potential 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/02/2024 02:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: COLOMA COTTAGE
FACILITY NUMBER: 306006274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2024
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by:
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Licensee to provide a written plan as to ensure facility is clean and sanitary and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure facility is clean and sanitary. There is a strong odor of urine in the facility. This poses a potential 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5