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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005392
Report Date: 03/22/2022
Date Signed: 03/22/2022 11:59:06 AM

Document Has Been Signed on 03/22/2022 11:59 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:TAYLOR COTTAGE, THEFACILITY NUMBER:
306005392
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:7752 TAYLOR DRIVETELEPHONE:
(614) 746-5824
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY: 6CENSUS: 4DATE:
03/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Wennie EarwoodTIME COMPLETED:
12:10 PM
NARRATIVE
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On this day Licensing Program Analysts (LPA) Jenifer Tirre and Andrea Mendivil made an unannounced visit to conduct a 10 day complaint investigation visit. During the walk through visit LPA's observed a caregiver not associated to facility which violates title 22 regulations. LPA's also observed a residents medications left out and not in a secured location. Licensee removed ointment medications from resident room and stored in secured location at LPA's request.

LPA's discussed violation of Title 22 regulations and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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Document Has Been Signed on 03/22/2022 11:59 AM - It Cannot Be Edited


Created By: Jenifer Tirre On 03/22/2022 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
HSC
87465(h)(2)

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87465(h)(2) incidental medical and dental care (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Facility put a note in Residents room for aides and nurses not to leave out medications after use. Adminstrator to remind staff about checking medications being locked. Facility will keep track of a medication sign out sheet each time meds are removed from secured location. poc due by 3/23/22
Type A
03/23/2022
Section Cited
HSC
87355(e)(2)

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87355(e)(2) Criminal record clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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facility makes sure prior to working that applicant has fingerprints completed along with criminal record clearance and is associated to facility. poc due by 3/23/22

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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