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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001789
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:21:46 PM

Document Has Been Signed on 05/23/2024 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MOORE VILLAGEFACILITY NUMBER:
306001789
ADMINISTRATOR/
DIRECTOR:		MINDY ANDREWSFACILITY TYPE:
735
ADDRESS:403 N. SUSAN STREETTELEPHONE:
(714) 480-0025
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 42CENSUS: 41DATE:
05/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:29 AM
MET WITH:Vanessa Lopez-Program ManagerTIME VISIT/
INSPECTION COMPLETED:
12:31 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on a self-reported incident regarding elopement. The incident report was received by Community Care Licensing (CCL) on May 22, 2024. LPA was greeted and allowed entrance into the facility by Program Manager (PM) Vanessa Lopez. LPA explained the reason for the visit.

LPA and PM conducted a toured of the inside and outside of the facility as well as bedroom of Client 1(C1). LPA reviewed and obtained pertinent documents such as Physician Report (LIC602) dated August 17, 2018 and the JHF-Moore Village Relapse Prevention Plan and Agreement (RPPA) dated February 2024 for C1. Per Physician report C1 is able to leave the facility unassisted. Per RPPA C1 agrees to not leave the JHF program grounds without the direct supervision of a staff or family member.

Incident report dated May 21, 2024 states that on the night of May 20, 2024 C1 left the facility and walked to the park. Per incident report C1 called 911 and was taken to the Hospital.

During today's visit LPA reminded PM of the importance to do a re-appraisal and obtain an updated Physician report in order to find out if the client has had a major change in condition and/or to determine if the client is a good fit for the facility. Per PM a re-assessment and a family meeting will be conducted once the client is discharged from the Hospital.

An exit interview was conducted with PM Lopez and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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