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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613273
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:02:52 AM


Document Has Been Signed on 03/10/2022 11:02 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:MORNINGSIDE OF FULLERTONFACILITY NUMBER:
300613273
ADMINISTRATOR:RICHARD ALLEN NORDSIEKFACILITY TYPE:
741
ADDRESS:800 MORNINGSIDE DR.TELEPHONE:
(714) 256-8000
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:712CENSUS: 408DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Cortez, Wellness Nurse & Nicki Hulquist, Resident Health Services DirectorTIME COMPLETED:
11:10 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), Kathrina Chin to follow up on resident 1 who self overdosed on Norco on 2/27/2022 and passed away on 3/3/2022. LPA arrived at facility and initially met with Jennifer Cortez, LVN/Wellness Nurse. Nicki Hulquist, LVN/ Resident Health & Services Director arrived thirty minutes later and LPA explained the nature of the visit. LPA Chin spoke to Richard Nordsiek, ED over the telephone upon arrival at the facility.

On 2/27/2022, resident 1 was sent out to the St. Jude Medical Center and returned to the skilled nursing facility, Park Vista, on 3/2/2022 of this Continuing Care facility. Resident 1 was placed on hospice on 3/3/2022 and passed away that evening. Resident 1 had a DNR and POLST on file. R1 was in the independent living section of the facility. LPA reviewed R1's physician's report and it was indicated that resident 1 is able to administrator her own prescription medications and was able to leave the facility unassisted.

LPA requested records such the Needs and Services plan, physician's report, pre-admission appraisal and medication list for resident 1 and was provided by Nicki Hulquist, RHSD. A copy of the hospital records from St. Jude Medical Center was also provided.



At this time, based on the information available, there are no deficiencies being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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