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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001989
Report Date: 06/08/2023
Date Signed: 06/08/2023 01:47:27 PM

Document Has Been Signed on 06/08/2023 01:47 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:CARING VILLAGEFACILITY NUMBER:
306001989
ADMINISTRATOR:MICHELLE DOMINGOFACILITY TYPE:
735
ADDRESS:8912 W. KATELLATELEPHONE:
(714) 484-6524
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 49CENSUS: 36DATE:
06/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Michelle DomingoTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Case Management - Incident to follow up on information regarding a Client's death. LPA met with Caregiver/MedTech Charlize Oviedo. Ms. Oviedo contacted Administrator (AD) Michelle Domingo to let her know of LPA's presence. AD Domingo arrived shortly after and LPA explained the purpose of today's visit.

During LPA's visit, LPA toured the facility, reviewed and obtained copies of pertinent documentation and conducted staff interviews regarding the death of Client 1 (C1) who passed away on 06/05/2023. LPA interviewed AD Domingo, and Staff 1 (S1) for further information regarding the death of C1 and the events that led up to C1's death. Per AD Domingo, the official Death Certificate has been not been issued at this time, as they are awaiting for the autopsy report from the Orange County Coroner's office.

There was no preliminary cause of death that was determined or provided. LPA advised AD Domingo to send a copy of the Autopsy report to the department as soon as it is available.

No deficiencies were cited during this visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (Confidential Names) will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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