306006310-5-10-2023-22-AS-CGUZ-CRPP8Z-20230510110622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006310
Report Date: 05/10/2023
Date Signed: 05/10/2023 11:06:43 AM

Document Has Been Signed on 05/10/2023 11:06 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 COTTAGE #2		FACILITY NUMBER:	306006310
ADMINISTRATOR:	SALONGA, MAUREEN		FACILITY TYPE:	740
ADDRESS:	26582 MORENA DRIVE		TELEPHONE:	(949) 310-2219
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 0	DATE:	05/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Maureen Salonga		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Maureen Salonga. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 1/23/2023. Structure: The facility is a one-story house with four resident bedrooms, three bathrooms, living room, kitchen, dining room, an activity room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room. There is a backyard with an exit gate on each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms Two out of four resident bedrooms had the required furnishings. LPA observed three out of three beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in garage and underneath the kitchen sink.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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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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 #2	FACILITY NUMBER: 306006310
	VISIT DATE: 05/10/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked closet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked with medication.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has magazines that are kept in the living and has an activity room with a television and various games, such as bingo and cards.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 03/08/2023. Special conditions noted “1 Bedridden approved in bedroom 1. 5 non-ambulatory approved in bedrooms 2-4. Caretakes are not sleeping on site.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 109.9-116.7 degrees Fahrenheit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COLOMA COTTAGE #2	FACILITY NUMBER: 306006310
	VISIT DATE: 05/10/2023

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Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting. Emergency phone numbers and food menu were not posted and visible.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Electric five burner stove with 1 oven, 1 refrigerator, microwave, washer, and dryer are operational.

Licensee to address the following corrections by 05/16/2023:

· Two out of four resident bedrooms had the required furnishings. Two out of four were observed to be free of any furnishings. All bedrooms must have all the required elements.

· Emergency phone numbers, Theft and Lost Policy, “Rights of Resident Councils” and food menu were not posted and visible.

· Fireplace was observed to be open. Fireplace must have a fireplace screen.

· Two out of two resident bathrooms do not have non-skid mats.

The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

An exit interview was conducted with designated AD and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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