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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006258
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:23:33 PM

Document Has Been Signed on 05/23/2024 12:23 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:IRVINE COTTAGE #3FACILITY NUMBER:
306006258
ADMINISTRATOR/
DIRECTOR:
ARNETT, KIMBERLYFACILITY TYPE:
740
ADDRESS:17 YORKTOWNTELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 6CENSUS: 5DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kimberly Walters, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Elinor Lagman, Caregiver. During today’s visit, LPA met with Kimberly Walters, Administrator (AD), Michelle Nesbitt, Compliance Manager, and Jozef Springer, Executive Administrator.

The facility is a single story building with an approved fire clearance of six non-ambulatory residents of which six may be on hospice. The facility currently has a census of five residents in care with three on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three of three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 106.8 and 110.8 degrees F and all smoke detectors were operational. There were two charged fire extinguishers that were serviced on April 11, 2024. The facility’s last fire/earthquake drill was conducted on March 1, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA conducted a complete review of resident and staff records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 21, 2024.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiency cited on this date. An exit interview was conducted with AD Kimberly Walters and a copy of the report was given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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