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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003765
Report Date: 07/13/2021
Date Signed: 07/13/2021 02:30:22 PM

Document Has Been Signed on 07/13/2021 02:30 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:IVY COTTAGES IFACILITY NUMBER:
306003765
ADMINISTRATOR:CARMEN RODRIGUEZFACILITY TYPE:
740
ADDRESS:9856 MARIPOSA AVENUETELEPHONE:
(714) 965-0412
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
07/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Carmen RodriguezTIME COMPLETED:
02:32 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. LPA met with Carmen Rodriguez, Administrator and explained the nature of the visit.

LPA began the tour of the facility accompanied by Administrator. The facility currently has 6 residents in care. LPA observed 2 residents in tv room and 4 residents in their bedrooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. LPA was checked in with temperature check and assessment upon entry. Facility keeps documentation in regard to covid for all the staff and resident. At 1:56pm LPA tested the hot water temperature in bathrooms which are used by the residents. The hot water temperature was measured at 105.8 Fahrenheit degrees. LPA observed facility has covid precautionary posting throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA observed facility has emergency food and water stored in attached garage. LPA observed first aid kits stored in medication closet. Facility has an sufficient supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside and observed a shaded outside space for resident, area is used for outdoor visitation area as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are currently 1 bedroom shared occupancy and 4 bedrooms single occupancy.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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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