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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006274
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:43:06 PM

Document Has Been Signed on 04/18/2024 03:43 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:COLOMA COTTAGEFACILITY NUMBER:
306006274
ADMINISTRATOR/
DIRECTOR:
SALONGA, MAUREENFACILITY TYPE:
740
ADDRESS:28901 LA LITA LANETELEPHONE:
(949) 218-0672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Anita Sacamay and Maureen SalongaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea made an unannounced Plan of Correction (POC) visit to the facility for the purpose of following up on citations issued on LIC form 809D during the annual required visit on 04/02/2024. LPAs were greeted and granted entry into the facility by Caregiver Anita Sacamay and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia (Inaccessible items) has been cleared. During today's visit, LPA observed noted items on LIC 809 are secured and inaccessible to residents in care. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. During today's visit, facility has no odor. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87355(e)(2) pertaining to Criminal Record Association has been cleared. LPAs observed Staff 1 is associated to the facility. Licensee has complied with the terms of the POC.

*Deficiency cited under Health and Safety Code 1565(c) pertaining to Emergency Drills has been cleared. Facility provided proof of emergency drill. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has NOT been cleared. LPA consulted with Licensee regarding training topics and reorganization of training proof and Licensee has agreed to resubmit training by close of business 04/25/2024.
Licensee addressed all items noted on the advisory note issued 04/02/2024.

Licensee has been advised to maintain all items especially those that were previously deficient in the facility in accordance with Title 22 Regulations.
Copy of this report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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