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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006329
Report Date: 06/21/2023
Date Signed: 06/21/2023 01:38:00 PM

Document Has Been Signed on 06/21/2023 01:38 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:FLORESTA COTTAGEFACILITY NUMBER:
306006329
ADMINISTRATOR:MANIAGO, MARIE JOYCE M.FACILITY TYPE:
740
ADDRESS:26982 FLORESTA LANETELEPHONE:
(917) 386-5767
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
06/21/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marie ManiagoTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by designated Administrator (AD) Marie Maniaga. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by CCL on 3/10/2023.

Structure:
The facility is a one-story house with 6 resident bedrooms, 3 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
All resident bedrooms had the required furnishings. LPA observed all windows were screened.

Signal system
There is a functional signal system that is audible throughout the facility. Each room has a signal control. There is a screen in the kitchen that identifies which resident room the signal came from.

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: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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: FLORESTA COTTAGE
FACILITY NUMBER: 306006329
VISIT DATE: 06/21/2023
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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:
A pool was observed to be enclosed in a fence in the backyard.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games and other types of games that are kept in the back yard and garage. Residents have their own selections of magazines and reading materials in their rooms

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 05/03/2023. Special conditions noted “1 Bedridden approved in bedroom 3. 5 non-ambulatory approved in bedrooms 1-2, 4-6. 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 116.1-117.1 degrees Fahrenheit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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: FLORESTA COTTAGE
FACILITY NUMBER: 306006329
VISIT DATE: 06/21/2023
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Linens & Hygiene Supplies:
A supply of extra linen was stored in each bedroom.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting. Emergency phone numbers and food menu were 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, dish washer, microwave, washer, and dryer are operational.

AD was informed today that the facility is ready for licensure and final approval will be processed by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was discussed with and provided to AD

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
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