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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005799
Report Date: 05/24/2021
Date Signed: 07/01/2021 02:29:53 PM

Document Has Been Signed on 07/01/2021 02:29 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:RAE'S COTTAGE AT PLACENTIAFACILITY NUMBER:
306005799
ADMINISTRATOR:OTBO, INESFACILITY TYPE:
740
ADDRESS:1265 SALVADOR DR. ETELEPHONE:
(562) 842-7539
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
05/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff Ernesto Espejo and Glenn MoroTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to facility to conduct an Annual visit. Upon arrival LPA met with Staff Glenn Moro and Ernesto Espejo and discussed the purpose of visit. Administrator Ines Otbo was contacted via telephone. She was not able to come to the facility due to a scheduled appointment.

During the visit LPA toured the facility inside and out with Ernesto Espejo. LPA observed Covid signage at the front entrance of facility as well as a sanitization station. A sign in sheet, thermometer and hand sanitizer were present. Facility has required Department postings. LPA observed a copy of Administrators Certificate for Ines Otbo expiring 1/24/23. LPA toured all resident rooms, all rooms appeared clean and sanitary. All restrooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves and paper towels. LPA observed outside visitation areas with ample shading. Three residents were observed resting in their rooms, two were watching tv in the family room and another was receiving physical therapy. Licensee has a Mitigation plan and Emergency Disaster Plan. A copy of the Mitigation Plan will be kept on file at the facility. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with Administrator and staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times.

No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Ernesto Espejo.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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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