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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530110
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:58:29 PM


Document Has Been Signed on 06/01/2023 01:58 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CATHY'S COTTAGE PALMSFACILITY NUMBER:
335530110
ADMINISTRATOR:BIRKINBINE, JULIEFACILITY TYPE:
740
ADDRESS:4221 SHOALCREEK DRIVETELEPHONE:
(951) 809-9571
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY:6CENSUS: 0DATE:
06/01/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Julie BirkinbineTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPAs) Victoria Chitgian and Mary Rico conducted an announced visit to complete a pre-licensing inspection and component III. LPAs met with Licensee Julie Birkinbine. The pending application is for a Residential Care Elderly for five (5) non ambulatory and one (1) bedridden resident.

The interior and exterior were toured of the pending facility. Overall, the pending facility is clean and of newer construction. There no pools or bodies of water. LPAs observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers faucets are functional. The hot water temperature was measured in the resident’s bathroom at 114 degrees Fahrenheit. Facility temperature was measured 72 Fahrenheit. LPAs observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manual. LPAs observed an adequate supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for residents use that includes a covered patio with a table and chairs. LPAs observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives are locked away inaccessible to residents. No firearms and ammunition will be kept in the facility.

Pre-Licensing is complete and has no deficiencies.

An exit interview was conducted where this report was discussed and provided to Julie Birkinbine.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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