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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005392
Report Date: 01/08/2025
Date Signed: 01/08/2025 05:08:47 PM

Document Has Been Signed on 01/08/2025 05:08 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:
01/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:01 PM
MET WITH:Licensee Wennie EarwoodTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On January 8, 2025, at 4:01pm, Licensing Program Analysts (LPAs) Edward Kim, Eboni Bentley, and Licensing Program Manager (LPM) Lourdes Montoya conducted a case management deficiency visit observed during an unrelated complaint # 22-AS-20250102163823.

During inspection visit, department observed the following deficiencies not related to complaint investigation.

Per observation and interview with the Licensee Weenie Earwood, Staff #1, and Staff #2 that medications for three residents (R1-R3) were transferred from the original container to a different container. LPA observed the temporary containers with medications inside the kitchen drawer.

In addition, per observation, record review and interview with Licensee, the facility does not have a certified administrator or a designee. Per the department’s interview with the listed administrator on file, former employee (S3) stated they have not been working for the facility at least for a year and a half and they have no intention to return to work as an administrator.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with Licensee Earwood and copy of report and appeal rights were provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/08/2025 05:08 PM - It Cannot Be Edited


Created By: Edward Kim On 01/08/2025 at 04:11 PM
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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87465(h)(5)

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87465...(h)...(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement was not met as evidenced by:
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Licensee agreed to not to transfer medications from original container to a different container. Licensee will provide training to staff on the section cited above and will send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date.
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Based on observation and interviews, LPA observed that resident #1, resident #2, and resident#3 had medication transferred from original container into a different container for three out of four residents. This poses a potential health, safety, and personal rights risk to all persons in care.
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Type B
01/10/2025
Section Cited
CCR87405(a)

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87405... (a) All facilities shall have a qualified and currently certified administrator… When the administrator is not in the facility, there shall be coverage by a designated substitute...
This requirement was not met asevidenced by:
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Licensee stated they agreed to submit the requirements for the change of administrator by POC due date January 10, 2025. Licensee will associated administrator upon approval of the documents..
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Based on observation, record review, and interviews, the facility did not have an administrator or designee on premises for at least year and a half. This poses a potential health, safety, and personal rights risk to all 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:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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