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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001408
Report Date: 05/24/2024
Date Signed: 05/28/2024 01:20:59 PM


Document Has Been Signed on 05/28/2024 01:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PARK PLAZAFACILITY NUMBER:
306001408
ADMINISTRATOR:BENJAMIN DAVISFACILITY TYPE:
740
ADDRESS:620 S. GLASSELL STREETTELEPHONE:
(714) 997-5355
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY:115CENSUS: 97DATE:
05/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Debbie Marroquin, Resident Relations Director (RRD)TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident report submitted to the department on May 14, 2024 by Assisted Living Director (ALD), Christina Gonzalez.

The purpose of this visit is for a case management incident where a client eloped from the facility on May 10, 2024 and was found by Orange Police Department (PD) on a nearby street. LPA requested resident file and evening staffing roster for May 10, 2024.

LPA interviewed resident (R1) to ensure she was okay. Resident did not recall PD finding her and stated she, "took off by herself on a long walk." Reviewing R1's file she is unable to leave the facility unassisted but is able to walk around the building. R1 usually has a friend with her or is in an activity walking during the day but the incident took place in the evening around 7:15pm. The concierge did not see R1 leave the facility. ALD took the call from PD and the son happened to be entering facility at the same time.

LPA interviewed S1,S2, S3 and ALD. On November 13, 2023 ALD noted a change in condition with R1. On April 10, 2024 NP with Senior Doc stated R1 is, "incapable of making an informed decision..because of the patient's condition, which includes dementia." Prior to the incident R1 did not have exit seeking behavior and checks in with concierge whenever she walks outdoors.

Based on LPA observations and interviews there was adequate staffing, with two medical technicians, three aides and the ALD. After the incident ALD spoke with the son and agreed to use a wander guard for R1. ALD is initiating a care plan meeting for R1 to move to Memory Care due to the progression of cognitive decline. Currently they are awaiting urinalysis results to determine if there are other underlying issues.

An exit interview was conducted with RRD Debbie Marroquin and a copy of this report was provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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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