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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600816
Report Date: 07/06/2022
Date Signed: 07/06/2022 02:14:25 PM


Document Has Been Signed on 07/06/2022 02:14 PM - 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: 200DATE:
07/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Claudia Lusca-BorcsaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management. LPA was greeted, granted entry by staff and explained the reason for the visit.

The purpose today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Regional Office July 1, 2022.

On today's visit LPA Haley discussed the incident report regarding Resident 1 (R1) with Administrator (AD) Claudia Lusca-Borcsa. LPA Haley received copies of R1's Admission Agreement, Face Sheet, Physicians Report, Individual Service Plan, and Kaiser Discharge Report.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted with Administrator Claudia 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: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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