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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005799
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:41:37 PM

Document Has Been Signed on 07/19/2024 01:41 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:RAE'S COTTAGE AT PLACENTIAFACILITY NUMBER:
306005799
ADMINISTRATOR/
DIRECTOR:
OTBO, INESFACILITY TYPE:
740
ADDRESS:1265 SALVADOR DR. ETELEPHONE:
(562) 842-7539
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 5DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator, Ines OtboTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 7/19/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregiver, Ernesto Espejo who was informed of the purpose of the visit. Administrator, Ines Otbo arrived during the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and has an approved hospice waiver for six (6).

LPA toured the facility with Caregiver Espejo and observed the facility is made up of a one-story home with six (6) resident bedrooms, two (2) full bathrooms, a staff room, kitchen, dining room and attached garage. During the tour, Caregiver Espejo tested two (2) of the smoke alarm/carbon monoxide detectors and LPA observed them to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. A brick wall secured the backyard. Medications are stored in a dining room cabinet that is secured with a master lock. Resident bedrooms had the required furniture and lighting. The hot water temperature in the resident bathrooms measured at 105- and 107- degrees Fahrenheit. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. The facility also has additional clean linens, towels along with hygiene and incontinent supplies stored in a hallway closet. LPA reviewed random staff and resident files. Resident files reviewed had signed admission agreements and updated medical assessments. Staff files reviewed had a criminal record clearance and a valid first aid/CPR certification.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Administrator Otbo.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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