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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606831
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:41:27 PM


Document Has Been Signed on 09/21/2022 03:41 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: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: 61DATE:
09/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Facility Administrator - Joel NiblettTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAS) Celine De Perio and Albert Marin conducted an unannounced case management visit at facility to follow up on the incident reports (SIR) that occurred between two residents on 9/16/22 and 9/17/22. LPAs were greeted and granted entry by facility administrator (AD) Joel Niblett, Assistant Director Jackie Arreaga, and Clinical Director Jean Guevara. For today's visit, there are a total of 61 residents in care.

LPAs De Perio and Marin conducted a tour of the interior portion of the facility with AD Niblett and toured resident #1's (R1) room and resident #2's room (R2) and conducted interviews with both residents. LPAs De Perio and Marin reviewed the files and Physician's Reports for R1 and R2

LPAs De Perio and Marin discussed California Code of Regulations Section 87466 Observation of the Resident.

For today's visit, no deficiency was noted for areas observed. No citation was issued.

LPAs De Perio and Marin conducted an exit interview with AD Niblett, Assistant Director Jackie Arreaga, and Clinical Director Jean Guevara, and a copy of this report, along with the regulation discussed was left in the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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