374603738-7-20-2023-18-AS-JSRS-CTX4V3-20230720192542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603738
Report Date: 07/20/2023
Date Signed: 07/20/2023 07:25:46 PM

Document Has Been Signed on 07/20/2023 07:25 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NORTH COUNTY COTTAGE		FACILITY NUMBER:	374603738
ADMINISTRATOR:	MARI DEE SANDRA CID		FACILITY TYPE:	740
ADDRESS:	221 W 6TH AVE		TELEPHONE:	(760) 743-7133
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	13	CENSUS: 12	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Mary Jane Estiller, Administrator		TIME COMPLETED:	07:30 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 Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual visit. LPA met with Administrator Mary Jane Estiller, and informed her of the purpose of the visit. Facility is approved for thirteen (13) elderly residents, ages 60 and above; all whom may be non-ambulatory; in which four (4) residents may be bedridden. Facility has a hospice waiver for six (6) residents. LPA conducted resident and staff interviews. The facility is one-story with nine (9) bedrooms and bathrooms in each room. Three (3) rooms are private and the rest are shared, two (2) in each room. There is one main shower room. LPA inspected the facility inside and out. The front entrance, interior and exterior surroundings were inspected and observed to be clean and in good repair with no pathway obstruction; facility's temperature throughout the facility measured at 75 degrees. Facility's water temperature measured at 105.3 degrees. All bathrooms were inspected and observed to be clean with working toilets and sinks. There is sufficient lightings and mattress pads in all of the residents’ bedrooms. Smoke and carbon monoxide detectors were inspected and found to be in working order. LPA inspected the fire extinguishers and they were found to be in compliance. Cleaning solutions were observed in a locked secure area. There were no bodies of water observed on the premise. The facility does not have firearm and/or ammunition on grounds. LPA observed the kitchen area and there are 7 day non-perishable and 2 day of perishable food items was observed and found to be properly stored. All required postings are posted in the hallway area of the facility. Staff records were reviewed. All staff present have a criminal record clearance on file and are properly associated to the facility.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NORTH COUNTY COTTAGE	FACILITY NUMBER: 374603738
	VISIT DATE: 07/20/2023

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Continued 809...

Random resident records were reviewed. LPA observed they had the required documentation and physicians reports are up to date. LPA inspected medications and medications appear to be dispensed appropriately according to the physician's orders. Last fire drill was conducted June 27, 2023.

No deficiencies were observed during today's annual inspection. An exit interview was conducted and a copy of the report and LIC 811 was provided to Administrator Mary Jane Estiller.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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