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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306000372
Report Date:
06/01/2022
Date Signed:
06/01/2022 11:48:12 AM
Document Has Been Signed on
06/01/2022 11:48 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:
ATRIA DEL SOL
FACILITY NUMBER:
306000372
ADMINISTRATOR:
GOODWIN, JEREMIAH
FACILITY TYPE:
740
ADDRESS:
23792 MARGUERITE PKWY
TELEPHONE:
(949) 458-1176
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92692
CAPACITY:
120
CENSUS:
85
DATE:
06/01/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
11:21 AM
MET WITH:
Jeremiah Goodwin and Irma Arreola
TIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident report submitted to Community Care Licensing on 05/24/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Jeremiah Goodwin and Resident Services Director Irma Arreola were present during the visit.
Incident report dated 05/22/2022 indicated Resident 1 (R1) was discovered by staff outside the facility in the parking lot. Staff redirected the resident back into the facility. Facility placed a one on one care companion with resident and advised family the companion would be needed until results of a urinalysis were received. Urinalysis was negative and family notified that R1 would need a permanent care companion or move into the memory care unit. Family declined and moved the resident out of the facility. Resident has had three documented elopements in the last 6 months. Physician report dated 05/24/2022 and 05/05/2021 both indicate a diagnosis of Dementia.
No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Kimberly Lyman
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/01/2022
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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