306006582-1-15-2025-22-AS-RMAZ-DCXVQV-20250115153857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006582
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:39:12 PM

Document Has Been Signed on 01/15/2025 03:39 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:	BAYSIDE COTTAGES III		FACILITY NUMBER:	306006582
ADMINISTRATOR/ DIRECTOR:	DIZON, BENJIE		FACILITY TYPE:	740
ADDRESS:	1565 WINTERGREEN PLACE , COSTA		TELEPHONE:	(949) 506-8933
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 14		CENSUS: 7	DATE:	01/15/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Benjie Dizon		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 Analysts (LPAs) Ruth Martinez and Hanna Gough conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Benjie Dizon, applicant. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (14) capacity, (0) ambulatory, (14) non-ambulatory, and (0) bedridden resident was submitted to CCL on 04/24/24. Structure: The facility is a one story house with an attached garage with 7 resident bedrooms, 3 full bathrooms, 1 half restroom, a living room, a dining room, a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is shaded seating areas in the backyard for resident and an exit walkway on each side of the house. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 14 residents with 7 bedrooms being shared. Bedrooms #6 & 7 have their own bathroom. Bedrooms Staff: No staff designated bedroom.Bathrooms: Facility has 4 full bathrooms and 1 half restroom. All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen in storage. 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 7-day non-perishable and 2-day perishables will be stored in the kitchen. Additional food storage in garage in spare refrigerator Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BAYSIDE COTTAGES III	FACILITY NUMBER: 306006582
	VISIT DATE: 01/15/2025

NARRATIVE

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and a freezer and a pantry located in garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. 2 fire extinguishers mounted in bedroom hallways, charged, and dated April 10, 2024, there is 1 fire extinguisher mounted in the garage charged with service date of June 20, 2024. Smoke detectors are maintained and serviced through a vendor called Alarm Central. Appliances: There is 2 Gas 5 burner stoves, 3 ovens, 3 refrigerators (kitchen/garage), a freezer, microwave, dishwasher, washers, and dryers are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and in the garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 108.3 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication will be stored in a locked storage closet located in hallway. First Aid kit stored with medication and book is stored with files. Resident & Staff Files: Records will be kept locked in storage cabinets located in the dining room. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on June 26, 2024. Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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