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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003767
Report Date: 07/13/2021
Date Signed: 07/13/2021 04:28:28 PM

Document Has Been Signed on 07/13/2021 04:28 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 IIIFACILITY NUMBER:
306003767
ADMINISTRATOR:CESAR RODRIGUEZFACILITY TYPE:
740
ADDRESS:16840 MT.EDEN STREETTELEPHONE:
(714) 775-1128
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
07/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Carmen Rodriguez, AdministratorTIME COMPLETED:
04:45 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 today’s visit.

LPA began the tour of the facility accompanied by caregiver. The facility currently has 6 residents in care. LPA upon entry LPA was checked in with temperature check and covid questioner. LPA observed 4 residents in living room watching a movie. All resident were observed to be relaxed and well taken care of. Facility appears clean and sanitary in all areas inspected. Facility staff screens all visitors to the facility, LPA observed a screening station in the entry of the facility. Facility keeps documentation for all covid related information for all visitors, staff, and residents. LPA observed facility has logs through out the facility. At 3:44pm LPA tested the hot water temperature in bathrooms which are used by residents. The hot water temperature was measured at 117.3 Fahrenheit degrees. LPA observed facility has covid precautionary postings though out the facility as well as required department postings. Facility has an active covid-19 prevention plan in place for the safety or resident in care. LPA observed facility has emergency food and water. First aid kits were observed to be store with medication. LPA inspected the 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 has single occupancy bedrooms for all 6 residents.

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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