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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003766
Report Date: 07/13/2021
Date Signed: 07/13/2021 03:35:40 PM

Document Has Been Signed on 07/13/2021 03:35 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 IIFACILITY NUMBER:
306003766
ADMINISTRATOR:CARMEN RODRIGUEZFACILITY TYPE:
740
ADDRESS:16827 MT. EDEN STREETTELEPHONE:
(714) 531-2185
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
07/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Carmen Rodriguez, AdministratorTIME COMPLETED:
03:37 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 immediately began the tour of the facility accompanied by caregiver. The facility currently has 6 residents in care. LPA upon entry was check in with temperature check and covid questioner. Upon entry LPA observed two residents in the living room. All resident in care appeared to be well taken care of. Facility appeared to be clean and sanitary. Facility staff screens all visitors to the facility upon entry, LPA observed screening station in the main entry of the facility. It was observed that facility keeps documentation in regard to covid for all the visitors, staff and residents. At 2:50pm LPA tested the hot water temperature in bathrooms which are used by the residents. The hot water temperature was measured at 105.6 Fahrenheit degrees. LPA observes that facility has covid precautionary postings through out the facility as well as all required department postings. LPA observed facility has a 30 day supply of medication, first aid kits are stored with medication. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA observed the emergency food and water supply. Facility has PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces of the facility. LPA toured the outside of the facility and observed a shaded seating area for resident’s enjoyment, area is used for outdoor visitation as well. Facility has a plan in place for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are single occupancy.

Based on the observation 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 LIC809 report was provided and left at the 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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