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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000752
Report Date: 07/20/2020
Date Signed: 07/20/2020 02:23:41 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:ATRIA GOLDEN CREEKFACILITY NUMBER:
306000752
ADMINISTRATOR:WENTWORTH, NICOLEFACILITY TYPE:
740
ADDRESS:33 CREEK RDTELEPHONE:
(949) 786-5665
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:155CENSUS: 100DATE:
07/20/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nicole Wentworth - Executive Director
April Princesa - Resident Services Director		TIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Patricia Velazquez contacted the facility via telephone to conduct a Case Management visit telephonically due to the COVID-19 Pandemic and pre-cautionary measures. LPA Velazquez spoke with Executive Director (ED) Nicole Wentworth, identified herself and discussed the purpose of the visit. The purpose of this Case Management visit was to follow-up on a Special Incident Report (SIR) received by LPA Velazquez on July 20, 2020 regarding Resident (R) #1.


At 1:45 PM LPA Velazquez along with Resident Services Director (RSD) April Princesa conducted a virtual tour utilizing FaceTime of R1's room. LPA also conducted interviews with facility staff. LPA also requested copies of pertinent records from R1's file.



There were no deficiencies issued during this Case Management visit. An exit phone interview was conducted with RSD April Princesa and a copy of this report was signed by LPA Patricia Velazquez. This report will be sent via email to RSD April Princesa who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. RSD April Princesa agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange. LPA Velazquez provided the RO address to RSD April Princesa.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2020
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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