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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006054
Report Date: 03/21/2025
Date Signed: 03/21/2025 12:52:14 PM

Document Has Been Signed on 03/21/2025 12:52 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:PAGEANTRY COTTAGE, THEFACILITY NUMBER:
306006054
ADMINISTRATOR/
DIRECTOR:		JABONERO, MACRINAFACILITY TYPE:
740
ADDRESS:125 PAGEANTRY DRTELEPHONE:
(714) 504-5371
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 4DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Macrina Jabonero, Administrator
Edna Tamondong, licensee		TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Licensee Edna Tamondong and Administrator Macrina Jabonero were notified by telephone and arrived later to assist with the visit.

There are currently four residents in care, three of which are receiving hospice care. LPA observed residents relaxing in their respective bedrooms and in the facility's common living areas, as well as having lunch in the facility's dining room. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has six private bedrooms and one staff room. There are three en-suite bathrooms and one shared bathroom throughout the facility.

Bedrooms appeared clean and sanitary. Three beds are observed to be equipped with full rails. The hospice plans of care for the respective residents were reviewed and verified to include an order for the postural supports. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and slip mats. Hot water temperature measured at 108F, 115F and 118F in three separate bathrooms with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in the secure drawer along with cleaning supplies in the laundry area. Medication central storage is stored securely in a locked closet. Fire extinguishers are charged and mounted, with up-to-date maintenance documented on the attached tags. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The attached garage is inaccessible to residents.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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: PAGEANTRY COTTAGE, THE
FACILITY NUMBER: 306006054
VISIT DATE: 03/21/2025
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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. There are self-latching gates on each route of egress. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress.

LPA reviewed four resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. Oxygen is in use and a sign was observed to be in place. There are no bedridden residents present on the premises. LPA reviewed staff records for six staff members. Records were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
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