<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600816
Report Date: 10/04/2022
Date Signed: 10/04/2022 11:35:13 AM


Document Has Been Signed on 10/04/2022 11:35 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ROWNTREE GARDENSFACILITY NUMBER:
300600816
ADMINISTRATOR:CLAUDIA LUSCA-BORCSAFACILITY TYPE:
741
ADDRESS:12151 DALE STREETTELEPHONE:
(714) 530-9100
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:280CENSUS: 202DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Claudia Lusca TIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit at Rowntree Gardens. LPA Haley was greeted upon entering the facility and explained the reason for today's visit. LPA Haley met with Administrator (AD) Claudia Lusca.

The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC624) that was sent to the Orange County Adult and Senior Care Program Regional Office September 28, 2022 that involved Staff 1 (S1).

During the visit LPA Haley received copies of S1's Medication Training Certificates, Certificate log, and In-Service Training Tracking Log.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC 811 was provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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 1