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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005990
Report Date: 09/13/2022
Date Signed: 09/13/2022 12:25:59 PM

Document Has Been Signed on 09/13/2022 12:25 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 AVETELEPHONE:
(310) 251-2382
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Maria Villanueva, Muqueet DadabhoyTIME COMPLETED:
12:40 PM
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On 09/13/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Pacifica Cottage. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 9:29am, LPA Cho was allowed entry into the facility and met with Caregiver Bryan Bernadino after completing the Coronavirus 2019 (COVID-19) screening procedure. Lead Caregiver Maria Villanueva was also present at this time. At 9:35am, LPA spoke to House Manager (HM) Jocelyn Tolentino via a telephone call and stated the purpose of today's visit. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. LPA observed the Complaint Poster (PUB475) in the size of 8.5"x11" which did not meet the size requirement. The facility is licensed for six non-ambulatory residents of which one may be bedridden and has a hospice waiver for six. There are currently six residents living in the facility of which one is receiving hospice care. The Administrator's Certificate for Muqueet Dadaboy expires on 03/27/23.

At 9:40am, LPA Cho conducted a tour of the physical plant along with Caregiver Villanueva. The single story home consists of six resident bedrooms and five resident bathrooms. There is one guest bathroom. The facility also has a family room, living room, dining area, kitchen, laundry area, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA observed a camera in the bedrooms of R1 and R2, and the cameras were immediately removed during the visit. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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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: PACIFICA COTTAGE
FACILITY NUMBER: 306005990
VISIT DATE: 09/13/2022
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LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 114.3 degrees Fahrenheit in the Bathroom #1, 115.0 degrees Fahrenheit in Bathroom #2, 114.6 degrees Fahrenheit in Bathroom #3, 115.1 degrees Fahrenheit in Bathroom #4, and 114.9 degrees Fahrenheit in Bathroom #5.

LPA Cho inspected the kitchen along Caregiver Villanueva. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching. There were no security bars or weapons on the premises.



LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components except a first aid manual, and the facility had sufficient PPEs. LPA reviewed the COVID-19 mitigation plan of the facility as well as Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility does have an existing internet service and provides the residents an iPad upon request.

At 11:26am, Licensee Muqeet Dadaboy entered the facility. LPA provided the following guidance: to enlarge the Complaint Poster (PUB475) that meets the size requirement of 20"x26," to obtain the current edition of the first aid handbook, to install an auditory device on the exit door in Bedroom #3, and to remove the cameras in Bedrooms #3 and #4 which were removed during the visit. In addition, LPA reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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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: PACIFICA COTTAGE
FACILITY NUMBER: 306005990
VISIT DATE: 09/13/2022
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Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Licensee Muqueet Dadaboy, and a copy of this report (including LIC809, LIC809C, LIC809D, LIC9102s, and the appeal rights) were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 12:25 PM - It Cannot Be Edited


Created By: Jessica Cho On 09/13/2022 at 11:47 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: PACIFICA COTTAGE
FACILITY NUMBER: 306005990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
(a) In addition to the rights listed in Section 87468.2, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews of staff and Administrator, the facility utilizes a camera in two out of six bedrooms and is not providing R1 and R2 a reasonable level of personal privacy which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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The cameras were removed during the visit, and licensee agrees to submit a night shift schedule of staff by POC due date to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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