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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881083
Report Date: 03/22/2022
Date Signed: 03/22/2022 12:48:33 PM


Document Has Been Signed on 03/22/2022 12:48 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, 1650 SPRUCE ST STE 200 MS29-27
, 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: 5DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Julie Birkinbine, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Amy Goldenberg and Rayshaun Nickolas made an announced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA was met at the door by Julie Birkinbine, Administrator. LPAs were granted entry into the home. She is wearing a mask. LPAs are informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the entry point. There is one entry point designated where sign in procedures and screening will occur.

LPAs conducted a brief tour of the facility 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 limited supply of Personal Protective Equipment (PPE). LPAs discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. There were no observable health and safety concerns noted during the physical plant inspection. The facility is maintained in a clean and organized fashion. The facility maintains digital records for residents and COVID screening with Synkwise electronic health records. All staff are medically cleared to work by a physician. All staff present have a criminal record clearance and are associated to the facility.

Based on observations made during today’s inspection, there are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. LPAs reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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