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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003767
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:47:32 AM

Document Has Been Signed on 07/26/2022 10:47 AM - 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:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Karla Cesena, Caregiver and Annie Gibbs, Office ManagerTIME COMPLETED:
10:46 AM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Rosie Quiroz was greeted, COVID-19 screened and granted entry into the facility by Live in Caregiver (LCG) Karla Cesena. LPA Rosie Quiroz explained the nature of the visit to (LCG) Karla Cesena. Office Manager (OM) Annie Gibbs and Licensee/ Administrator (L/AD) Carmen Rodriguez arrived to facility shortly after. Facility is licensed to provide service to 6 Non Ambulatory residents and has a hospice waiver for 3 residents. Facility is currently providing hospice services to two residents. Administrator has an Administrator certificate with expiration date of May 14, 2022. L/AD Carmen Rodriguez indicated she completed the certificate course, and currently still waiting for new Administrator certificate in the mail. L/AD Carmen Rodriguez agreed to submit certificate to CCL upon receiving it.
On or about 9:22am, LPA Rosie Quiroz along with (LCG) Karla Cesena began the tour of the inside and outside of the facility. There are six residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed five of six residents in living room area watching television and relaxing supervised by caregivers. Staff indicated Resident 5 is currently out with Family. Five of five residents present during today's visit appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility. LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility and a hand washing station in entrance of the facility.
All restrooms observed to have a supply of soap and appeared to be clean. Water temperatures in 3 of 3 bathrooms were recorded to be 105.6, 107.2 and 108.1 degrees Fahrenheit. LPA inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food and water in attached garage area. LPA observed the PPE supply in the facility readily available for use. LPA toured the outside of the facility and observed seating and shaded area for resident and visitor's enjoyment. The facility has completed the LIC 808 Mitigation Plan. The plan was received by the Department on April 7, 2021. LIC 808 Mitigation Plan was reviewed and approved by LPA Micah Martinez on April 7, 2021. LPA was informed that all residents and staff have had their COVID-19 vaccinations and one booster. CONTINUED NEXT PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IVY COTTAGES III
FACILITY NUMBER: 306003767
VISIT DATE: 07/26/2022
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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 (L/AD) Carmen Rodriguez, and a copy of this report, and LIC 811 Confidential Names was provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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