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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881083
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:43:38 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: 2DATE:
10/19/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Julie Birkinbine, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a post licensing inspection, with an emphasis on infection control due to the COVID-19 pandemic. The facility has an approved mitigation plan on file with this agency. There is screening of visitors upon entry into the facility. The facility uses caring data, a digital sign in system to clear visitors for entry. Upon entry LPA's temperature was taken and shown how to log into the facility. The front door is the single point of entry for the facility.

LPA conducted a brief tour and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a supply of Personal Protective Equipment (PPE). LPA provided information regarding this agency's availability of PPE supplies and advised the facility representatives to contact our office in the event additional supplies are necessary. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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