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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606831
Report Date: 04/25/2022
Date Signed: 04/25/2022 11:57:46 AM

Document Has Been Signed on 04/25/2022 11:57 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:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jennifer SuckielTIME COMPLETED:
12:15 PM
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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, administrator and explained the purpose of today’s visit. Incident was self reported on 03/14/2022 regarding R1’s incidents on 03/08/2022.

On 03/08/2022 R1 activated red alert pendant, facility nurse responded to the call. Upon arrival nurse observed R1 to be on the floor of the residents apartment kitchen. R1 reported to have hit the back of the head and a small laceration was observed. Facility nurse conducted first aid to R1 until paramedics arrived on scene. 911 was immediately called and paramedics arrived on seen and transferred R1 to local hospital for evaluation. R1 indicates that they felt light-headed and just fell back, R1 does not have a history of falls. R1 denies the loss of consciousness. All responsible parties were notified and R1 returned to the community. Facility conducted a Wellness check upon return to the facility. R1 followed up with primary physician. R1 has been doing well since incident.

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.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

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

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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