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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000752
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:21:14 PM


Document Has Been Signed on 12/13/2022 12:21 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:ATRIA GOLDEN CREEKFACILITY NUMBER:
306000752
ADMINISTRATOR:JAMES D. CRADDOCKFACILITY TYPE:
740
ADDRESS:33 CREEK RDTELEPHONE:
(949) 786-5665
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:155CENSUS: 104DATE:
12/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:James Craddock- Executive Director TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 12/08/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Executive Director James Craddock.

Unusual Incident/Injury Report (LIC 624) was received on 12/08/2022 for an incident that occurred on 12/08/2022. Per LIC 624 Resident 1 (R1) advised medtech they took incorrect dosage. Medtech called 911 and paramedics came to assess R1. R1 was then transferred hospital and admitted overnight, R1 returned on 12/09/2022 without new orders.

Per interview with Staff 1 (S1) noticed that R1 did not appear well. R1 told S1 that they believe they took double dosage of self - administered medication. S1 then called 911 to have R1 assessed.

Review of LIC 602 indicates R1 cannot administer own medications but doctors orders dated 09/26/2022 state R1 can self administer 1 medication.

During the visit LPA reviewed LIC 602 and Doctors Orders dated 09/26/2022.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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