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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606831
Report Date: 05/09/2022
Date Signed: 05/09/2022 10:37:32 AM


Document Has Been Signed on 05/09/2022 10:37 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:FREEDOM VILLAGEFACILITY NUMBER:
300606831
ADMINISTRATOR:MARIANNE CASINO/ J.NIBLETTFACILITY TYPE:
741
ADDRESS:23442 EL TORO ROADTELEPHONE:
(949) 472-4733
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:533CENSUS: 366DATE:
05/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer SuckielTIME COMPLETED:
10:50 AM
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) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted by receptionist and granted entry. LPA met with Jennifer Suckiel, Executive Director and explained the purpose of today’s visit. Incident was self reported on 04/29/2022 regarding independent living resident R1’s incidents on 04/22/2022.

On 04/22/2022 R1 activated red alert pendant, facility nurse responded to the call. Upon arrival nurse observed R1 to be seating upright on the floor by the bed. R1 reports that they were walking towards their bed and they lost their balance and fell. 911 was immediately called and paramedics arrived on seen and transferred R1 to local hospital for evaluation. Facility nurse conducted first aid to R1 until paramedics arrived on scene. R1 indicated to having pain in their right hip, R1 does not have a history of falls. All responsible parties were notified. R1 has not yet returned to the community as they will be check in to skilled nursing for further treatment of fall. R1 is an independent living resident that does not require a needs and services plan. R1 is ambulatory and is able to ambulate independently. R1 will be re-evaluated prior to returning to the community for any changes in condition.

LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPA did not observe any immediate and/or safety risks in or out of the facility.

This report was reviewed with facility representative and a copy of this report was provided and left at the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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