306006348-7-20-2023-22-AS-DLMN-CTWRDD-20230720125545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006348
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:56:46 PM

Document Has Been Signed on 07/20/2023 12:56 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MC COTTAGE		FACILITY NUMBER:	306006348
ADMINISTRATOR:	CONSTANTINO, RAUL		FACILITY TYPE:	740
ADDRESS:	24962 WILKES PLACE		TELEPHONE:	(949) 481-9064
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6		CENSUS: 0	DATE:	07/20/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Raul Constantino, Administrator and Lorna Constantino, Applicant		TIME COMPLETED:	12:45 PM

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) Dwayne Mason Jr. and (LPM) Armando Lucero made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA & LPM arrived at the facility at 9:40am and were greeted and granted entry by designated Administrator (AD) Raul Constantino. 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 Community Care Licensing (CCL) on 6/2/2023. Structure: The facility is a one-story home with six resident bedrooms, three and a half bathrooms, living room, kitchen, dining room, one staff bedroom, an attached three car garage and an attic accessible through the garage. Photos of the stairway to the attic door were taken. LPA observed the attic to be storage for chemicals, paint, tools, hardware, and picture frames. LPA also observed a lock on the door to prevent resident access. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in one of the hallways. There is a back yard with two exit gates on each side of the house. There are two seating areas in the backyard, one of which is shaded. LPA did not observe any obstacles or hazards in the backyard. LPA observed that the facility used to have a swimming pool that has been filled in. LPA obtained photos of the pool that has been filled in. LPA inquired about any permits needed to fill in the swimming pool, Administrator stated that they did obtain permits by the city, but did not have the permit on-hand. Administrator is to submit a copy of the permit to LPA via email by due date. LPA observed a fireplace covered by glass doors in the living room. Client Bedrooms: All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. There is auditory signal sent out whenever one of the doors leading outside of the house is opened. Resident Room #3 has a sliding door leading to the walkway in front of the house. AD changed the settings of the door signal system so that a unique sound plays when the door in Resident Room #3 is opened.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MC COTTAGE	FACILITY NUMBER: 306006348
	VISIT DATE: 07/20/2023

NARRATIVE

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Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the garage in locked cabinets.

Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet in the staff room. First aid kit is stored on the wall in the living room. The first aid kit has all the required elements.

Resident & Staff Files: Records will be kept locked in storage cabinet located in the garage.

Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a receipt of purchase for the fire extinguisher which indicates the fire extinguisher was purchased on 5/23/23.

Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept on the kitchen patio area. Puzzles, Bingo, card games, other games and books will also be kept for resident use.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 05/24/2023.

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

Bedrooms Staff: One bedroom will be occupied by staff that is located along the hallway.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 114.9 degrees Fahrenheit in the half bathroom, 115.3 degrees Fahrenheit in the bathroom along the hallway across from the staff room, 113.5 Fahrenheit in the bathroom along the hallway between Resident Room #2 and the Master Bedroom, and 112 degrees Fahrenheit in the master bathroom.

Linens & Hygiene Supplies: A supply of extra linen was stored in cabinets in the garage.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MC COTTAGE	FACILITY NUMBER: 306006348
	VISIT DATE: 07/20/2023

NARRATIVE

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Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

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

The following correction is needed before applicant is ready to be licensed:

1. Email to LPA a copy of the permit from city granting them permission to fill in pre-existing pool.

The due date for this correction is Tuesday, July 25, 2023 by close of business (COB)

Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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