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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002233
Report Date: 06/30/2021
Date Signed: 06/30/2021 12:27:09 PM

Document Has Been Signed on 06/30/2021 12:27 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:RAINBOW COTTAGEFACILITY NUMBER:
306002233
ADMINISTRATOR:HANH PHAMFACILITY TYPE:
740
ADDRESS:24301 LYSANDA DRIVETELEPHONE:
(949) 455-7376
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
06/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced required annual inspection in this facility. Via phone, LPA spoke with Administrator (AD) Hahn Pham and stated the purpose of this visit. AD was currently out in the area and gave permission for staff to receive the report.

The facility is single level structure licensed for capacity of six non-ambulatory, and with hospice waiver for four. For this visit, there were two residents under hospice care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA observed four residents in the dining area, one in the bedroom and two staff members on the floor. One resident was out of the facility. About 11:35 AM, LPA toured the interior and exterior portions of the facility. There were four private and one shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were provided with grab bars; non-skid loor mats, and hot water was measured at 115 degrees Fahrenheit. Facility met the two-day perishable and seven-day non-perishable minimum food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion of the facility, patio furniture were observed in to be in good repair, and grounds were free of tripping hazards. Exterior exit door was self-closing and self-latching.

LPA reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with lead staff member. LPA left a copy of this report in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2021
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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