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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000697
Report Date: 09/28/2021
Date Signed: 09/28/2021 02:12:07 PM

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:GRANNY'S PLACEFACILITY NUMBER:
306000697
ADMINISTRATOR:SIMPSON, RONALD P.FACILITY TYPE:
740
ADDRESS:24132 DELPHI STREETTELEPHONE:
(949) 380-1861
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
09/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Delia Pardo and Romulus VillanuevaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on a death report reported to Community Care Licensing on 09/21/2021. LPA was greeted and granted entry into the facility by Caregiver Romulus Villanueva and explained the reason for the visit. Administrator Delia Pardo and Licensee Ron Simpson arrived during the visit.

Death report dated 09/21/2021 indicated Resident 1 (R1) was sent out via 911 for poor balance and slurred speech on the morning of 09/14/2021. R1 subsequently passed away at Saddleback Hospital on 09/15/2021. Facility staff indicate R1 had poor balance the day prior to hospitalization. Facility staff deny R1 had any fall at the facility and R1 had a one on one caregiver present at night on 09/12/2021 and 09/13/2021. Per physician report dated 10/20/2020, R1 is diagnosed with A-Fib and Hypertension. Medication records indicate R1 is currently prescribed Eliquis for stroke prevention and Metroprolol for hypertension. Per facility staff, R1's responsible party indicates cause of death as a brain bleed. Family to provide death certificate to facility as soon as its available.

Facility to forward a copy of death certificate to LPA upon receipt.



Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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