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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003766
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:54:03 PM

Document Has Been Signed on 12/17/2024 03:54 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY COTTAGES IIFACILITY NUMBER:
306003766
ADMINISTRATOR/
DIRECTOR:		CARMEN RODRIGUEZFACILITY TYPE:
740
ADDRESS:16827 MT. EDEN STREETTELEPHONE:
(714) 531-2185
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Carmen Rodriguez-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:06 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Ricardo Peralta. Administrator (AD) Carmen Rodriguez arrived shortly after.

For today’s visit, LPA observed a total of six residents in care and three staff members on duty.

During today's visit LPA observed the AD certificate for AD Carmen Rodriguez which expires on May 21, 2026.

LPA toured the interior and exterior portions of the facility with AD. The facility is a one story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of seven bedrooms, of which six are resident bedrooms and one staff bedroom. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 108.3-109.0 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the kitchen and one in the garage.

During today's visit LPA observed the residents eating chicken with vegetables, mash potatoes, salad and fruit for lunch.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IVY COTTAGES II
FACILITY NUMBER: 306003766
VISIT DATE: 12/17/2024
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LPA observed the emergency disaster and evacuation plan which is located by entryway. Facility had back-up emergency food and water supply.

LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. The medications are locked in a cabinet by the kitchen.

For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which is both is self-closing and self-latching. No bodies of water were observed.

LPA reviewed six resident files and three staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA advised AD to use the general email address:


CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Rodriguez.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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