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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006310
Report Date: 04/23/2025
Date Signed: 04/23/2025 03:37:17 PM

Document Has Been Signed on 04/23/2025 03:37 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COLOMA COTTAGE #2FACILITY NUMBER:
306006310
ADMINISTRATOR/
DIRECTOR:		SALONGA, MAUREENFACILITY TYPE:
740
ADDRESS:26582 MORENA DRIVETELEPHONE:
(949) 310-2219
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
04/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Anthony Coloma- Adminstrator
Marianne Salonga- Lead Staff		TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Lian Tjia and explained the reason for the visit. Administrator (Admin) Anthony Coloma arrived on premise to assist with the inspection. Admin Anthony holds a valid certificate expiring on November 25, 2025 and October 24, 2025 for Administrator Maureen Salonga.

The facility is a single story structure and is licensed to provide services for age range 60 and over for six non-ambulatory, of which one may be bedridden in bedroom #1. Facility can provide hospice services to six residents at one time. During today's visit, there are two out of six residents under hospice care and three caregivers on duty.

LPA toured the physical plant with Admin Anthony and Lead Staff Marianne Salonga. LPA observed five resident bedrooms and three resident bathrooms. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 109.0, 108.3, and 108.1 degrees Fahrenheit. All common areas were inspected including the attached two car garage. LPA observed sufficient emergency food and water. Disaster supplies indicated on the Emergency Disaster Plan (LIC610E) were not maintained. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. Both exit gates were self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was mounted and serviced in March 2025. The auditory devices and smoke/carbon monoxide detectors were tested and operational.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/23/2025 03:37 PM - It Cannot Be Edited


Created By: Jessica Cho On 04/23/2025 at 02:50 PM
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 #2
FACILITY NUMBER: 306006310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of six resident's physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Administrator stated that a procedure to track annual medical assessments will be in place and proof of the updated LIC602 for R1 will be submitted to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COLOMA COTTAGE #2
FACILITY NUMBER: 306006310
VISIT DATE: 04/23/2025
NARRATIVE
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Emergency evacuation drills are conducted quarterly. Last known drill was conducted on February 3, 2025. The facility land line number, (949) 446-6898, was tested and remains available. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size.

LPA conducted a file review of all residents and two staff files. A discrepancy was noted as the Physician's Report (LIC602) for Resident #1 (R1) was not updated. There were no concerns with staff files. Medications were audited, and interviews were conducted during today's visit.

The following items were addressed during the exit interview: to acquire emergency supplies as documented on the LIC610E and to ensure the LIC602s are updated as needed.

Based on the observations made during today's visit, a deficiency is being cited and an Advisory Note (LIC9102) is being issued.

An exit interview was conducted Administrator Anthony Coloma and Lead Staff Marianne Salonga, and a copy of this report including the LIC809C, LIC809D, LIC9102, and the appeal rights were provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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