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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600816
Report Date: 03/10/2022
Date Signed: 03/10/2022 09:26:45 AM


Document Has Been Signed on 03/10/2022 09:26 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: 201DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Claudia Lusca-BorcsaTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit for the purpose of conducting a Case Management visit regarding an Unusual Incident Report (LIC 624) received from the facility on 03/09/2022. LPA was greeted at the reception desk by facility staff and explained the reason for the visit today. LPA met with the staff at Skilled Nursing Facility and she contacted via telephone, Assisted Living Administrator Claudia Lusca-Borcsa and informed her I was here.

LPA Haley interviewed AD Lusca-Borcsa to follow up on the March 3rd incident regarding Resident 1 (R1).

On 03/03/2022, R1 was found in in a sitting position bleeding profusely from the nose. A body assessment was done and noted R1 had an abrasion to the face, left cheek pain, and left eyebrow hematoma. First aid was applied and paramedics transferred R1 to West Anaheim Medical Center for evaluation.

LPA Haley was provided copies of R1's: Admission Agreement, Face sheet, Incident Investigation Summary, Physician's Report, and Needs and Service plan.

LPA explained if further follow up is required, LPA Haley will return at a later date and time for further information and details regarding this incident. No deficiencies cited at this time.

An exit interview was conducted with Administrator Lusca-Borcsa and a copy of this report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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