Coloma Cottage #3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Administrator Assistant/Caregiver Marianne Salonga and explained the reason for the visit. Administrators (Admins) Maureen Salonga arrived on premise to assist with the inspection followed by Anthony Coloma. Admins Maureen and Anthony hold a valid certificate expiring on November 25, 2026 and October 24, 2026. The following was observed during the inspection: This is a single story home comprised of five resident bedrooms and two resident bathrooms. There is an additional bedroom occupied to by two live-in staff. Facility operates within the conditions and limitations specified on the license. LPA observed six residents in care and two caregivers on duty with one nocturnal staff off duty during the visit. All staff were fingerprint cleared and associated. All common areas were inspected which includes the attached two car garage which also serves as a storage and laundry area. LPA inspected all bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found be in compliance, clean, and operational. Slip resistant mats were provided. The hot water temperature in the resident bathrooms measured at 108.1 and 108.6 degrees Fahrenheit. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food in the kitchen and pantry. LPA tested and observed all four burners lit unassisted. The toxins, disinfects, sharps, and medications were secured and inaccessible. A working telephone number, (949) 600-7099, remains available. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The two exit gates on each side of the property were functional, and there were sufficient seating and shading in the patio area. The fireplace was appropriately screened. The two fire extinguishers were serviced monthly with the last service date of September 2025. The dual functioning smoke/carbon monoxide detectors and all auditory devices tested operational. LPA observed emergency food/water/disaster supplies in the garage. The first aid kit had all necessary elements. Facility is not conducting quarterly emergency drills. The last known date was on September 29, 2025. Admin stated that the drill will be conducted per shift next month. The Complaint Poster (PUB 475) was posted in the correct size. LPA reviewed three personnel and six resident files in which no discrepancies were found. LPA inspected two out of six residents' medications and no discrepancies were found. Admin was advised to conduct quarterly emergency drills per shift. Based on the observations made during today's visit, no deficiencies are being cited. An Advisory Note is being issued. An exit interview was conducted with Administrators Maureen Salonga and Anthony Coloma, and a copy of this report were provided at exit.the state’s words, verbatim · CDSS document, Nov 6, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

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 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.the state’s words, verbatim · CDSS document, Nov 4, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Method: Telephone call with CAB COMP II Participants: Coloma, Sherwin & Malone, Matthew On 9/30/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 30, 2024