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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005611
Report Date:
06/21/2021
Date Signed:
06/21/2021 11:59:15 AM
Document Has Been Signed on
06/21/2021 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:
BEECHWOOD COTTAGE, THE
FACILITY NUMBER:
306005611
ADMINISTRATOR:
OTBO, INES N
FACILITY TYPE:
740
ADDRESS:
1608 BEECHWOOD AVE
TELEPHONE:
(714) 255-7917
CITY:
FULLERTON
STATE:
CA
ZIP CODE:
92835
CAPACITY:
6
CENSUS:
5
DATE:
06/21/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:18 AM
MET WITH:
Ines Otbo, Administrator
TIME COMPLETED:
12:12 PM
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Licensing Program Analyst (LPA) Jim August conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Glenn Moro and explained the reason for the visit. Administrator Ines Otbo arrived shortly after.
LPA August toured the facility with Glenn Moro. There are five residents residing in the facility and no active covid-19 cases. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Bathrooms had disposable towels and the facility staff are aware that no community shared towels are to be used. Resident bedrooms appeared clean and sanitary and had all required components.
Facility is taking temperatures daily and documenting results. The facility has an approved LIC808 Mitigation Plan on file. Facility has back-up emergency food and water supply.
No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
James August
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/21/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2021
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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