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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881083
Report Date: 03/25/2021
Date Signed: 03/26/2021 12:30:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CATHY'S COTTAGE - ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
331881083
ADMINISTRATOR:BIRKINBINE, JULIEFACILITY TYPE:
740
ADDRESS:4089 INVERNESS DRIVETELEPHONE:
(951) 809-9571
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY:6CENSUS: 0DATE:
03/25/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Julie Birkinbine - Applicant TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin conducted an announced pre-licensing video conference inspection to the facility due to COVID-19. LPA Colvin met with Applicant Julie Birkinbine. Currently there are 0 residents in care.

The facility is a single-story house with four (4) resident bedrooms, three (3) bathrooms, a living room, family room. kitchen, dining room, and garage. The location does not have any pools, ponds, or large bodies of water on the premises. The facility will be providing Dementia/Memory Care services and has an approved Hospice Waiver for six (6) residents. On 1/5/21, the Corona Fire Department approved the facility for five (5) non-ambulatory residents and one (1) bedridden resident.

During today's inspection, LPA Colvin conducted a virtual tour of the interior and exterior of the facility. The facility is at a comfortable temperature of at least 68 degrees. The medications will be centrally stored and locked in a cabinet in the kitchen. Sharp objects are locked in a cabinet inside a drawer located in the kitchen. The facility is equipped with night lights in the hallways and passages. The smoke and carbon monoxide detectors are operable, as observed by LPA Colvin when tested they were tested today during the inspection. All cleaning supplies are locked in the laundry room. All doors, and passageways are clear from obstruction.

All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items. There was appropriate lighting and furniture in each room. The facility is stocked with a 2-day supply of perishables and a 7-day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity. LPA Colvin observed the emergency disaster plan, facility sketch, personal rights, and complaint procedures that are hanging on a board in the facility. The facility is stocked with activities to provide entertainment and encourage socialization for the residents including books, games, crafts, and television.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CATHY'S COTTAGE - ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 331881083
VISIT DATE: 03/25/2021
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LPA Colvin additionally observed the facility to have COVID-19 precautions in place with personal protective equipment for staff and resident use, such as face masks, gloves, and hand sanitizer.

An exit interview was conducted, and a copy of this report was reviewed and provided to Applicant Julie Birkinbine via email to obtain signature.

Receipt of report was confirmed.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
LIC809 (FAS) - (06/04)
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