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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005392
Report Date: 06/13/2024
Date Signed: 06/13/2024 12:10:49 PM

Document Has Been Signed on 06/13/2024 12:10 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:TAYLOR COTTAGE, THEFACILITY NUMBER:
306005392
ADMINISTRATOR/
DIRECTOR:		CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:7752 TAYLOR DRIVETELEPHONE:
(614) 746-5824
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY: 6CENSUS: 4DATE:
06/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Caregiver, Quitin ClavecillasTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an announced inspection visit to conduct a pre licensing visit for separate facility license Taylors Loving Care for a change of ownership. During inspection visit LPA observed Resident Room 5 is being used as a Passageway through to staff bedroom. This poses an potential health, safety and/or personal rights risk to persons in care.

Based on the observations made during today's visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights was provided to staff.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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Document Has Been Signed on 06/13/2024 12:10 PM - It Cannot Be Edited


Created By: Jenifer Tirre On 06/13/2024 at 11:52 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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87307(a)(2)(c)

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 87307 (a) living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accomodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(2)
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Licensee agree to correct access from resident bedroom to staff bedroom. by POC date 06/21/2024
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resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: resident's room is a passageway to staff room. Based on observation the licensee did not comply with section cited above in one resident room which poses a potential health, safety or personal rights risk to persons in care.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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