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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006274
Report Date: 02/22/2023
Date Signed: 02/24/2023 09:16:51 AM

Document Has Been Signed on 02/24/2023 09:16 AM - 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:COLOMA COTTAGEFACILITY NUMBER:
306006274
ADMINISTRATOR:SALONGA, MAUREENFACILITY TYPE:
740
ADDRESS:28901 LA LITA LANETELEPHONE:
(949) 218-0672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 5DATE:
02/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maureen SalongaTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA), Lydia Martinez conducted an announced visit at this facility for the purpose of completing a Pre-Licensing evaluation. Facility is an existing facility and undergoing a Change of Ownership. There are 5 residents in care under the current license. An initial application to operate a Residential Care For the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 11/22/2022 for a capacity of 6 residents. LPA met with Applicant Maureen Salonga.
Facility is a one story, 4 bedroom, 2 bathroom house with an attached garage. Facility is secured by a fence on both sides of the property. Adequate seating is available in the dining room as well as the living room. LPA observed an operational television in the living room. Only one resident bedroom of the 4 bedrooms is double occupancy and all are equipped with appropriate lighting, chair, night stand and ample closet space. Resident bathrooms have a working toilet, wash basin, and walk-in showers. Linen supply is in ample supply for residents. Facility has a current food supply of two day perishables and seven day non-perishables. LPA observed the emergency water supply. Smoke and carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins were locked/stored in a closet in the garage. Hot water in bathroom was tested and is within regulatory requirements. First Aid kit observed contained all required items. Medication is stored and locked in a locked cabinet in the dining room. Files are stored in same locked cabinet. The facility has activity supplies such as board games and puzzles. LPA observed staff exercising and singing with residents. Facility has a large backyard with patio table, chairs and a huge umbrella for shade. Exit gate is unlocked and self latching. Fire clearance is approved for 5 non-Ambulatory, of which one could be Bedridden on 12/27/2022.
The Component III Requirement was completed during todays visit. The Pre-Licensing is complete and this facility has no deficiencies. All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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