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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001989
Report Date: 06/01/2022
Date Signed: 06/01/2022 10:55:54 AM

Document Has Been Signed on 06/01/2022 10:55 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:CARING VILLAGEFACILITY NUMBER:
306001989
ADMINISTRATOR:MICHELLE DOMINGOFACILITY TYPE:
735
ADDRESS:8912 W. KATELLATELEPHONE:
(714) 484-6524
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 49CENSUS: 41DATE:
06/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michelle Domingo, AdministratorTIME COMPLETED:
11:15 AM
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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 Michelle Domingo regarding a self reported incident regarding resident 1.

On 5/29/22, resident 1 failed to return to facility by their curfew. Resident is alert and able to leave facility unassisted. Facility staff filed a missing person's report with Garden Grove Police. Resident's 1 physician's report dated April 14, 2022 and it indicates that resident is able to leave unassisted. Resident returned on May 31, 2022 at 2:45 AM. Resident was sent out the same day to Crisis Stabilization Unit(CSU) of the Orange County Health Care Agency Behavioral Health Services. Resident continues to remain CSU and will return sometime today. Ms. Domingo stated that CSU called this morning that they will return the resident to the facility today. Ms. Domingo stated that resident will be seen by her psychiatrist tomorrow, June 2, 2022. Ms. Domingo will hold a conference with the resident and OCHCA Planned Coordinator in regards to resident breaking house rules and will receive a written warning.

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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