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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001789
Report Date: 06/08/2022
Date Signed: 06/08/2022 12:55:31 PM

Document Has Been Signed on 06/08/2022 12:55 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:MOORE VILLAGEFACILITY NUMBER:
306001789
ADMINISTRATOR:MINDY ANDREWSFACILITY TYPE:
735
ADDRESS:403 N. SUSAN STREETTELEPHONE:
(714) 480-0025
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 42CENSUS: 41DATE:
06/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Program Manager Vanessa LopezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst Michelle Reed arrived at the facility to follow up on an unusual incident report sent to the Licensing Office on 6/6/22. Upon arrival, LPA met with Program Manager Vanessa Lopez. Administrator Mindy Andrews was scheduled to come to the facility later today.

On 6/5/22 at approximately 7:20pm staff noted that Resident #1(R1) was not on property. Staff searched the property and looked in every room. R1 could not be located. Program Manager Vanessa Lopez was contacted as well as the family of R1. 911 was contacted at 8:20pm. A missing person's report was filed at approximately 9:00pm. with the Santa Ana Police Department.

On 6/7/22, in the afternoon, R1 was located by a family friend in the City of Orange, near the Orange Circle. R1 was picked up by family and taken to the ER in Fountain Valley. R1 did not have any injuries and returned to the facility 6/7/2022 at 7:00pm.

Records were reviewed for R1 and copies were made. The facility did have an Absentee Notification Plan on file. According to Program Manager Vanessa Lopez, the Licensee is working on an elopement plan specific to R1 and a copy will be provided to Licensing by 6/13/22.

No citations issued per Title 22 regulation at this time.

An exit interview was conducted with Program Manager Vanessa Lopez and Administrator Andrews (via telephone) and a copy of this report was provided to Program Manager Vanessa Lopez.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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