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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006578
Report Date: 11/04/2024
Date Signed: 11/04/2024 01:58:50 PM

Document Has Been Signed on 11/04/2024 01:58 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 #3FACILITY NUMBER:
306006578
ADMINISTRATOR/
DIRECTOR:		MALONE, MATTHEWFACILITY TYPE:
740
ADDRESS:26481 MORENA DRIVETELEPHONE:
(949) 310-3108
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
11/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Maureen Salonga, ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting a pre-licensing inspection. LPA was greeted and granted entry by Maureen Salonga, applicant.

An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on May 13, 2024 for a capacity of six non-ambulatory residents. This is an initial application to operate a facility at this location, however licensee already operates two other licensed facilities. The applicant has requested a hospice waiver for a capacity of six.

LPA accompanied by applicant toured the physical plant. The facility is a one-level home with a frontyard, backyard and attached two-car garage. There are two private and two shared bedrooms along with two bathrooms located in the central hallway, both with walk-in showers. An additional room will be assigned to be a staff room. Necessary components of furnishing for all six bedrooms are observed to be present alongside an adequate supply of linen and bedsheets. Faucets used for personal hygiene are verified to be operational. Water temperature measured in both bathrooms at 112.7F and 113.1F. Grab bars and slip mats are in place in both bathrooms. Common living spaces are present and furnished as required. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present. The current administrator certificate is observed to have expired on October 15, 2024. Administrator certificate was however verified to be pending with the Department at the time of the visit.

Kitchen equipment is present and operating as required. Sharp items are stored in a drawer secure by a magnetic lock. Cleaning supplies are secured in the attached garage. A secure cabinet is also present in the kitchen. A sufficient supply of perishable and non-perishable food will be placed on the premises prior to the first residents' move-in. The centrally stored medication storage will be located in a secure closet where the first aid kit is also observed to be present and complete. The laundry area is located inside the attached garage. Sound alarms are present on the ways of egress and verified to be in operation.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 #3
FACILITY NUMBER: 306006578
VISIT DATE: 11/04/2024
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CONTINUED FROM FORM LIC809
The fire clearance has been obtained on May 21, 2024 and provided to the Department before the pre-licensing visit. All bedrooms are cleared for non-ambulatory residents and one room equipped with a fire door and direct outdoor evacuation access is cleared for a bedridden individual. Combined smoke and carbon monoxide detectors are observed throughout the facility and confirmed to be functional. Fire extinguishers present on the premises are observed to be charged and newly purchased. Proof of liability insurance coverage provided for one of the two other current licensed location and will be extended once licensed. Telephone service is present. Facility staff will use a tablet for residents needing online access.

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and multiple shaded areas are present. The perimeter gates present on both sides of the house are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises and delayed egress is not in use.

Component III was waived as the prospective licensee has already been acting as the current licensee and operator for two other licensed locations. This report was reviewed with facility representative and a copy of this report was emailed to the applicant before the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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