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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005999
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:21:34 PM

Document Has Been Signed on 01/22/2025 12:21 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:COTTAGES AT ARTESIA, THEFACILITY NUMBER:
306005999
ADMINISTRATOR/
DIRECTOR:		OLAIS, AURELIAFACILITY TYPE:
740
ADDRESS:6041 KINGMAN AVENUETELEPHONE:
(800) 570-2273
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 55CENSUS: 49DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:07 AM
MET WITH:Aurelia OlaisTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On this day Licensing Program Analysts (LPAs) Samer Haddad and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 55 non-ambulatory residents. Facility has an approved hospice waiver for 25 residents and the home currently has 49 residents, with 15 residents on hospice. Administrator (AD) Aurelia Olais arrived shortly to help conduct facility tour. AD Olais has renewed her Administrators certificate and is currently pending as of 9/30/2024. AD provided updated liability insurance that expires on 7/17/2025.
LPAs along with staff Paula Tanglao toured the facility at 8:30 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The facility is a one-story complex with twenty-eight resident apartments. Each apartment has either its own private bathroom or shares a jack-and-jill style bathroom with another apartment. The facility also houses two common bathrooms, three large shower rooms, kitchen, dining room, living room, sun room, laundry room, activity room and medication room. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 117.5 degrees F and 120.5 degrees F in all bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked behind the kitchen entrance door during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Stove in kitchen has 3 out of 6 burners non-operational. LPAs observed one kitchen drawer to have rotted out. Facility is planning to replace all cabinets on 1/27/2025. LPA reviewed cabinet quote provided by Fireworks Fire Protection Services. Smoke detectors were serviced on 1/6/2025. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/17/2024. Outside grounds were toured. Walkways around the facility were clear of hazards.
Continued on LIC809-C Dated 1/22/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COTTAGES AT ARTESIA, THE
FACILITY NUMBER: 306005999
VISIT DATE: 01/22/2025
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There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, bingo, and music therapy. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPAs observed the emergency food and water supply. LPAs reviewed five resident files and five staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. At 9:00am, Medications were observed stored in a medication room that was unlocked with a med-tech present in the room at the time of visit. Some medications were on the counter. The medication room has an open wall facing the main entrance of the facility.

Based on the observations made during today’s visit, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/22/2025 12:21 PM - It Cannot Be Edited


Created By: Fred Arias On 01/22/2025 at 11:08 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: COTTAGES AT ARTESIA, THE
FACILITY NUMBER: 306005999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff interview, some medications are routinely left unlocked on the counter of the medication room which poses an immediate safety risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Facility placed medications in a locked push cart during the visit.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/22/2025 12:21 PM - It Cannot Be Edited


Created By: Fred Arias On 01/22/2025 at 11:41 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: COTTAGES AT ARTESIA, THE
FACILITY NUMBER: 306005999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation 3 out of 6 stove burners were not operational which poses a potential safety or risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Facility will repair the stove and sent pictures to LPA as proof of correction.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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