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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003767
Report Date: 01/29/2025
Date Signed: 01/29/2025 11:08:27 AM

Document Has Been Signed on 01/29/2025 11:08 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY COTTAGES IIIFACILITY NUMBER:
306003767
ADMINISTRATOR/
DIRECTOR:		CESAR RODRIGUEZFACILITY TYPE:
740
ADDRESS:16840 MT.EDEN STREETTELEPHONE:
(714) 775-1128
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Administrator Carmen RodriguezTIME VISIT/
INSPECTION COMPLETED:
11:23 AM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator (AD) Carmen Rodriguez was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Carmen Rodriguez has a valid Administrator certificate which expires on May 21, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, with a hospice waiver for three. The facility is a single story home with six private resident bedrooms, three resident bathrooms, two of which are shared, one staff room, a living room, a family room, a kitchen, a dining room, a laundry room, an attached three car garage, and a shed located in the backyard. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care, two of which are on hospice, and three caregiver staff present. LPA observed residents eating breakfast in the dining room and relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the family room. LPA inspected the six resident bedrooms and they were observed to be free of hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident linens and blankets to be clean. LPA observed additional linens stored in a cabinet in the resident hallway. LPA observed that the staff room is kept locked and inaccessible to residents in care. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 109 and 109.7 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 III
FACILITY NUMBER: 306003767
VISIT DATE: 01/29/2025
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LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in the kitchen and it was observed to be charged and serviced as of August 13, 2024. LPA tested the individual smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on January 15, 2025. The centrally stored medication is stored in a locked closet by the dining room. LPA observed a First Aid Kit to be stored in the locked closet. LPA inspected the First Aid Kit and observed it to have all the required components. The door leading to the laundry room is kept locked and inaccessible to residents in care. LPA observed chemicals and toxins to be stored in a cabinet in the locked laundry room. The door leading to the attached three car garage is kept locked and inaccessible to residents in care. LPA observed the two car garage is used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA accompanied by the AD toured the exterior portion of the facility. LPA observed the exterior portion to be free of obstructions and hazards. LPA observed an shaded outdoor seating area with furniture for resident use. LPA inspected the shed/office located in the backyard. LPA observed the shed to be locked and inaccessible to residents in care. LPA observed the shed to be used for storage. The perimeter gate on the southside of the facility is self-latching and can be opened in an evacuation. There are no bodies of water located on the premises.

LPA reviewed all six resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed the six residents' medication and medication records. LPA reviewed four staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Carmen Rodriguez and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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