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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006567
Report Date: 01/15/2025
Date Signed: 01/15/2025 10:13:20 AM

Document Has Been Signed on 01/15/2025 10:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BAYSIDE COTTAGES IFACILITY NUMBER:
306006567
ADMINISTRATOR/
DIRECTOR:		DIZON, BENJIEFACILITY TYPE:
740
ADDRESS:1019 CHEYENNE STREETTELEPHONE:
(949) 506-8933
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
01/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Benjie DizonTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analysts (LPAs) Ruth Martinez and Hanna Gough conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Benjie Dizon, applicant.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden resident was submitted to CCL on 04/30/24.

Structure:
The facility is a two story house with an attached garage with 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms downstairs, a living room, a dining room, a kitchen on the first floor. The second floor of the facility will be occupied by licensee with one bedroom, a living room and 1 full bathroom. Staircase has a locked door for inaccessibility to resident, no resident will reside on the second floor. The resident’s bedrooms on the first floor are spacious and will easily accommodate the resident’s furnishings. There is shaded seating areas for resident and an exit walkway on each side of the house. There is resident shaded seating on the front yard of the facility that is enclosed with a gate. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with all room being private bedrooms. Resident bedroom in the main entry of the facility has its own bathroom. Bedrooms Staff: There is a bedroom designated for live in caregiver. Bathrooms: Facility has three full bathrooms on the first floor. All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen in storage located in bedroom hallway. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one
Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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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: BAYSIDE COTTAGES I
FACILITY NUMBER: 306006567
VISIT DATE: 01/15/2025
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week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables will be stored in the kitchen. A large pantry is in a closet storage located in the dining room area adjacent to the kitchen. Additional food storage in garage in spare refrigerator and a freezer located in garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. 1 fire extinguishers mounted in living, charged, and dated April 10, 2024. Appliances: Gas five burner stove, two ovens, two refrigerators (kitchen/garage), a freezer, microwave, dishwasher, 2 washers, and 2 dryers are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in the garage cabinet. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 118.5 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet located in the kitchen. First Aid kit and book are stored in storage closet adjacent to kitchen and main entrance of facility. Resident & Staff Files: Records will be kept locked in storage cabinets in the office located adjacent to the kitchen. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance:
Was approved on August 27, 2024. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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