<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005576
Report Date: 06/17/2021
Date Signed: 06/17/2021 11:29:28 AM

Document Has Been Signed on 06/17/2021 11:29 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:JC COTTAGES - HOLLYDALEFACILITY NUMBER:
306005576
ADMINISTRATOR:PARUNGAO, MARIAFACILITY TYPE:
740
ADDRESS:1013 N HOLLYDALE DRTELEPHONE:
(714) 519-3927
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 6CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Maria PagunaoTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Maria Parungao and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:
LPA and AD observed there were 2 staff present, wearing PPE. LPA observed 5 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen, and observed they were clean and organized. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

During the inspection, LPA and AD observed the following: in the kitchen, knives were accessible to residents in non-lockable cabinet and under-bench storage; in the laundry room, prescription medications, cleaning supplies (including laundry detergent), and scissors were accessible to residents in lockable but unlocked cabinets (with the keys hanging in immediate proximity) and non-lockable cabinets; in the unlocked garage, cleaning supplies (including bleach) were accessible to residents. During the inspection, AD and facility staff properly secured all of these items and LPA confirmed.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding screening, surveillance testing, visitation, resident outings, COVID-19 signs, PPE, changes in condition, physical plant, and N95 fit testing. LPA requested and reviewed resident roster, staff roster, staff files, emergency plan, and COVID-19 mitigation plan.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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 3
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: JC COTTAGES - HOLLYDALE
FACILITY NUMBER: 306005576
VISIT DATE: 06/17/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/17/2021 11:29 AM - It Cannot Be Edited


Created By: Sean Haddad On 06/17/2021 at 11:19 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: JC COTTAGES - HOLLYDALE
FACILITY NUMBER: 306005576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)


87303 Maintenance and Operation: (a) The facility shall be clean, safe.... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not ensure toxins, knives, and other dangerous items were inaccessible to residents in 3 out of 14 rooms/areas which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
1
2
3
4
Licensee immediately secured the toxins, knives, medications, and other dangerous items during today's inspection.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Marina Stanic
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3