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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005990
Report Date: 08/31/2021
Date Signed: 08/31/2021 01:27:03 PM

Document Has Been Signed on 08/31/2021 01:27 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:PACIFICA COTTAGEFACILITY NUMBER:
306005990
ADMINISTRATOR:DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:25421 PACIFICA AVE.TELEPHONE:
(310) 251-2382
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
08/31/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Administrator Muqeet DadabhoyTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Albert Marin made an announced visit to this facility to conduct a pre-licensing inspection and Component III orientation. LPA met with Administrator (AD) Muqeet Dadabhoy and stated the purpose of the visit.

On August 5, 2021 , The Orange County Fire Authority granted the fire clearance of 5 non-ambulatory and 1 bedridden for this single structure.

About 11:14 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA toured the interior and exterior portions of the facility. There three residents in care and two staff members on the floor. There were six private resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were tested to be operational. Call system was in place and tested to be operational. Bathrooms were observed to be in good repair, provided with grab bars and nonskid floor mats. Hot water was measured at 110 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. Side exit doors were self-closing and self-latching.

LPA Marin conducted the Component III Orientation with AD Dadabhoy.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

The Prelicensing and Component III Orientation are now complete. LPA Marin will provide copy of this report to the Centralized Applications Bureau for final determination.

LPA Marin conducted an exit interview with AD Dadabhoy; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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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