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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602548
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:46:08 PM

Document Has Been Signed on 11/08/2024 04:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KATELLA SENIOR LIVING COMMUNITYFACILITY NUMBER:
300602548
ADMINISTRATOR/
DIRECTOR:		CHRISTINE GREENWAYFACILITY TYPE:
740
ADDRESS:3952 KATELLA AVENUETELEPHONE:
(562) 596-2773
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 140TOTAL ENROLLED CHILDREN: 0CENSUS: 54DATE:
11/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Executive Director, Jon Peralez & Wellness Director Michelle DrinkardTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a case management to follow up on a self reported incident that occurred at facility on 11/3/2024. LPA Tirre met with Executive Director Jon Peralez and Wellness Director Michelle Drinkard.

LPA Tirre toured Physical Plant with Executive Director. The facility is a two level structure and is licensed for 140 residents. Currently, there is a total census of 54 residents in care of which 8 is on hospice. LPA observed resident rooms to be in good repair. LPA observed residents in common area dining room singing with music coordinator.


LPA conducted interviews with staff members aware of incident and Resident 1. LPA conducted file review for resident 1 and staff 1. LPA was unable to interview Staff 1 due to staff member no longer working at facility. LPA conducted interview with R1 and observed R1 had confusion with some questions. LPA observed R1's Physician report with diagnosis of Memory loss and mild cognitive impairment.

During visit LPA requested pertinent documents such as Personnel Report, Register of residents, corrective action notice, ID and Emergency information, Medication list and physician's report.

A LIC 811 Confidential names list was provided and exit interview was conducted and a copy of the report provided.
Lourdes MontoyaTELEPHONE: (714) 703-2870
Jenifer TirreTELEPHONE: (714) 401-6844
DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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