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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006274
Report Date: 03/18/2025
Date Signed: 03/18/2025 10:41:36 AM

Document Has Been Signed on 03/18/2025 10:41 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/
DIRECTOR:		SALONGA, MAUREENFACILITY TYPE:
740
ADDRESS:28901 LA LITA LANETELEPHONE:
(949) 218-0672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 4DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Maureen SalongaTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Coloma Cottage. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Anita Sacamay. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 1 resident on hospice during today's visit. Maureen Salonga has an Administrator Certificate expiring on 10/24/2026. Caregiver Audi Baldonasa and Administrator Maureen Salonga arrived during the visit.

LPA along with Caregiver Sacamay toured the facility at 7:52 AM. LPA toured the physical plant, checked food service, and the first aid kit. Facility appears clean and sanitary upon entrance. The home consists of four resident bedrooms, one resident bathroom, one shared hall bathroom, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed two residents with half bed rails. 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 122.3 and 125.2 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 8:10 AM, LPA observed unsecured sharps and pre-poured medications in a kitchen cabinet (photos). Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and exit gates are unlocked and self latching. There is ample outdoor shaded seating for residents. LPA observed emergency food and water supply in the facility. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of CONT ON LIC 9099C DATED 03/18/2025

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COLOMA COTTAGE
FACILITY NUMBER: 306006274
VISIT DATE: 03/18/2025
NARRATIVE
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last fire drill conducted on 02/12/2025. Facility provides activities in the form of games and exercise. At 8:45 AM, LPA reviewed four resident files and three staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation of health screen/ TB, criminal record clearance and CPR/ first aid training. One out of three staff do not have required staff training. At 9:15 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.


Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
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Document Has Been Signed on 03/18/2025 10:41 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/18/2025 at 09:59 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: COLOMA COTTAGE
FACILITY NUMBER: 306006274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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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4
Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured medications in a kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee to secure medications and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed pre-poured medications in a kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee to discontinue pre-pouring and provide confirmation statement to LPA by POC due date.
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:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/18/2025 10:41 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/18/2025 at 10:01 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: COLOMA COTTAGE
FACILITY NUMBER: 306006274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. Water temperature measured between 122.3 and 125.2 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee to adust water temperature and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/18/2025 10:41 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/18/2025 at 10:05 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: COLOMA COTTAGE
FACILITY NUMBER: 306006274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three staff did not have required training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2025
Plan of Correction
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Licensee to conduct training and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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