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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006310
Report Date: 05/19/2023
Date Signed: 05/19/2023 09:25:12 AM

Document Has Been Signed on 05/19/2023 09:25 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 #2FACILITY NUMBER:
306006310
ADMINISTRATOR:SALONGA, MAUREENFACILITY TYPE:
740
ADDRESS:26582 MORENA DRIVETELEPHONE:
(949) 310-2219
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
05/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maureen SalongaTIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection visit to follow up on corrections identified during visit on 05/10/2023. 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 Community Care Licensing (CCL) on 1/23/2023.

At 9:05 a.m. LPA toured the facility and observed the following:
  • Four out of four bedrooms have all the required elements.
  • Emergency phone numbers, Theft and Lost Policy, “Rights of Resident Councils” and food menu are posted and visible.
  • Fireplace was observed to have a fireplace screen.
  • Two out of two resident bathrooms have non-skid mats.

All noted items from visit on 05/10/2023 have been addressed.

The facility is ready to be licensed. An exit interview was conducted, 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: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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