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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881689
Report Date: 07/16/2025
Date Signed: 07/16/2025 10:00:14 AM

Document Has Been Signed on 07/16/2025 10:00 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ELLIS COTTAGE ASSISTED LIVING LLCFACILITY NUMBER:
331881689
ADMINISTRATOR/
DIRECTOR:		CUASAY, AURORAFACILITY TYPE:
740
ADDRESS:28310 ELLIS AVENUETELEPHONE:
(951) 878-7027
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 12CENSUS: 0DATE:
07/16/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:22 AM
MET WITH:Dante Bautista, ApplicantTIME VISIT/
INSPECTION COMPLETED:
10:05 AM
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On 07/16/25 Licensing Program Analyst (LPA) Javina George made an announced prelicensing inspection. LPA met with Applicant Dante Bautista whom accompanied LPA throughout the inspection. On 05/06/25 the Riverside County Fire department granted a fire clearance for six (6) non ambulatory residents only. The applicant has applied for a hospice waiver for (4).
The facility is a single story structure that consists of (1) shared resident bedroom (4) private resident bedrooms with (2) resident bathrooms and(1) staff bedroom and bathroom for the live in caregivers, kitchen, dining area, laundry room, backyard and detached garage. The bathrooms were observed to have grab bars, and non skid mats. The hot water measured within regulatory limits at 114.6 degrees Fahrenheit. All resident bedrooms have an exit ramp leading outside, and were observed to have adequate lighting, chest of drawers, chair and a bed. The facility was observed to have the required postings emergency disaster plan, Long Term Care Ombudsman poster, CCL complaint poster, Theft and Loss policy and personal rights. There are books and games available to encourage socialization. The facility was observed to have a fully stocked first aid kit and manual, as well as emergency supplies including a generator.
The fire extinguishers were serviced in May 2025, and were fully charged with the tag in tact. The sharps are stored in a locked drawer inside the kitchen next to the sink. The chemicals are stored in a double locked cabinet underneath the kitchen sink. The facility has combined smoke and carbon monoxide detectors were then tested and found to be operable. There are no known guns or ammunition, or pools/bodies of water on the premises. The emergency shut off for water and gas are stored in the underground cellar, in the back of the building.
The medications, resident and staff files will be stored in a locked file cabinet inside the office area. The facility was observed to have ample amount of linen, dishes and utensils that are in good repair. The applicant successfully completed COMP III orientation on 07/08/25. Based on today's inspection the facility is ready for licensure. An exit interview was conducted and a copy of this report was reviewed and provided to Dante Bautista, applicant.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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