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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006468
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:34:11 PM

Document Has Been Signed on 04/25/2024 03:34 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:DEVONSHIRE COTTAGEFACILITY NUMBER:
306006468
ADMINISTRATOR/
DIRECTOR:		ALDIANO, ANNAFACILITY TYPE:
740
ADDRESS:23416 DEVONSHIRE DRTELEPHONE:
(949) 590-7014
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 0DATE:
04/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Anna Aldiano - Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by Administrator Anna Aldiano. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by Community Care Licensing (CCL) on 12/8/2023.

The facility is a one-story home with five resident bedrooms, three and a half bathrooms, living room, den, dining room, kitchen, covered patio, backyard and 2-car garage. There is a staircase that leads to an office upstairs, however only the first floor is seeking license. There is a locked door preventing resident access to the second floor.



Client Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened.

All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 120, 118.6, 118.4 and 118.8 degrees Fahrenheit in the resident bathrooms..

LPA observed the fire extinguishers to be fully charged as indicated by the arrow pointing in the green zones on their meters. LPA observed tags indicating the extinguishers were filled/charged in 2024.

Medication and First-Aid Kit will be locked in a closet near the entryway. Resident & Staff Files will be locked in drawers in the dining area.
The fire clearance was approved by a fire inspector of Orange County Fire Authority on 2/13/2024.
LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and are stored and locked in the garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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: DEVONSHIRE COTTAGE
FACILITY NUMBER: 306006468
VISIT DATE: 04/25/2024
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A supply of extra linens is stored in a cupboard in the hallway. A supply of extra hygiene supplies is stored in the garage.

Emergency Phone Numbers and Exit Plan are all posted and available for review. LPA observed other necessary postings in the hallway. LPA observed an activity calendar and menu.

Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational. Resident bedroom doors are equipped with alarms to notify staff if a resident goes outside. Facility also has pendant alert system.

Operational appliances include a gas stove, oven, two refrigerators, dishwasher, microwave, washing machine and dryer.

LPA reviewed and provided Administrator with the Component III presentation to offer information and resources regarding maintaining facility compliance.

The designated AD was notified that the final application approval will be issued by the Centralized
Applications Bureau in Sacramento. 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: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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