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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606398
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:18:10 PM


Document Has Been Signed on 05/17/2022 12:18 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:YORK RETIREMENT HOMES, INC.FACILITY NUMBER:
300606398
ADMINISTRATOR:JACOBSEN, DONALDFACILITY TYPE:
740
ADDRESS:22391 LOMBARDITELEPHONE:
(949) 770-1348
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 0DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Donald JacobsenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to this facility to conduct a case management. LPA meet with Donald Jocobsen, Administrator and explained the purpose of this visit via telephone call.

On May 4, 2022 LPA was informed that the home had been sold and Licensee had sent Sacramento HQ the renewal notice of annual fees with no longer interested in operating the facility. On May 11, 2022 LPA received by email notification with the following information: Facility was closed on February 15, 2022. The three residents in care moved out of the facility. Two resident moved out by family and one resident was moved to one of the other York Retirement homes on February 8, 2022. LPA was also informed the home had been sold and Licensee no longer had control of the property as of April 29, 2022.

For this visit, LPA toured the exterior portion of the facility. From the outside, LPA Martinez did not observe any residents in care. LPA observed observed work trucks working on the home and no sign of care being provided.
LPA Martinez conducted and exit interview with Administrator and provided a copy to Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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