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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000889
Report Date: 06/01/2022
Date Signed: 06/01/2022 02:22:35 PM

Document Has Been Signed on 06/01/2022 02:22 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:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:JO DEE GIBSONFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 76CENSUS: 42DATE:
06/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jo Dee Gibson, Executive DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Kathrina Chin made an unannounced site visit as a follow up to a case management- incident. LPA Chin identified herself and explained the purpose of the visit. LPA spoke Jo Dee Gibson, Executive Director and Lida Spicer, LVN, regarding a self reported incident regarding resident 1.

On 5/19/22, resident 1 went outside to smoke and left the facility premises around 2:30 PM without signing out or informing staff. Resident returned to the facility on 3 PM. LPA reviewed resident's physician report dated 5/10/2022 and resident does not have wandering behavior and is not confused or disoriented. Lida Spicer stated that a wander guard was placed on resident 1's scooter.

No deficiency cited this review as per Title 22 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
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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