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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000889
Report Date: 04/08/2024
Date Signed: 04/08/2024 11:02:08 AM


Document Has Been Signed on 04/08/2024 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:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:KAT FARRISFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:76CENSUS: 30DATE:
04/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kat FarrisTIME COMPLETED:
11:17 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report/ SOC 341 received by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report/ SOC 341 dated 04/02/2024 indicated that on 04/01/2024, Resident 1 (R1) told staff that a registry caregiver had been rough and unprofessional with the resident the night before. Staff assessed resident and observed discoloration on the resident's right upper arm. Facility alerted resident's family, physician and licensing. Resident's physician assistant ordered an x-ray for 04/04/2024. X-ray was performed with no fracture or dislocation detected. Facility notified registry of alleged incident and requested caregiver not return to facility. OC Sheriff was notified and interviewed resident. Resident denied abuse or harm from caregiver. During the investigation, LPA interviewed Resident 1 who denied any abuse or harm as well from caregiver. Resident verbalized feeling safe at the facility. LPA observed bruising on resident's arm which resident indicated came from the resident falling in the shower and the caregiver attempting to break the fall. Per physician order dated 03/12/2024, Resident is diagnosed with Mild Cognitive Impairment and is taking Eliquis twice daily. No further action required.



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: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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