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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600816
Report Date: 10/25/2021
Date Signed: 10/27/2021 08:48:13 AM

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: 186DATE:
10/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Claudia LuscaTIME COMPLETED:
04:30 PM
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
This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Kathrina Chin to follow up on an incident reported to Community Care Licensing. LPA spoke to with Claudia Luska, Executive Director over the telephone and met Celeste Gonzalez, Administrative Assistant and explained the purpose of today’s visit. LPA made a case management visit in order to address five incident reports dated 9/17/2021, 9/28/2021, 10/8/2021, 10/9/2021, and 10/20/2021. The following incidents occurred:

It was reported that resident 1 (R1) on 9/17/2021 who resides in the Dementia Unit fell on his way to the bathroom. He sustained a hematoma to his left eye and left forearm skin tear. The facility called 911 emergency personnel and transferred to UCI Medical Center. R1 remains in Rowntree's skilled nursing facility.

On 9/28/2021, Resident 2 fell at the courtyard and hit her head on the pavement and was bleeding. The facility dialed 911 emergency personnel. R2 sustained three staples on her head. Resident has returned to the community.

There are two incidents concerning resident 3 (R3) on 10/8/2021 and 10/9/2021. It was reported on 10/8/2021 that R3 fell in the bathroom and sustained a laceration to her head. The facility called 911 emergency personnel and sent her to West Anaheim Medical Center. She returned to the community at 4:20 AM. On 10/9/2021, a nurse checked on R3 and found the resident was more lethargic and the 2 staples on her head was bleeding excessively. The nurse contacted 911 emergency personnel and the resident was taken to UCI Medical Center. R3 remains at Rowntree's skilled nursing facility.

Resident 4(R4) fell in her room and had right hip pain and 911 emergency personnel was contacted. Resident was taken to Garden Grove Hospital. R4 sustained a hip fracture and is currently at Rowntree's skilled nursing facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy was provided.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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