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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 05/08/2020
Date Signed: 05/12/2020 02:34:33 PM

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:SUNRISE AT YORBA LINDAFACILITY NUMBER:
306002568
ADMINISTRATOR:MARIA DOMINGOFACILITY TYPE:
740
ADDRESS:4792 LAKEVIEW AVETELEPHONE:
(714) 693-5368
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:93CENSUS: 79DATE:
05/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Viola Kaake & Maria DomingoTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and discussed the self-reported incident that the facility reported with Administrator, Viola Kaake, Reminiscence Coordinator.

LPA Chin conducted a tele-visit via Facetime with care staff member, Staff 1 (S1) who reported that Staff 2 (S2) handled resident 1 roughly when resident 1 required incontinent changing. S1 stated that this incident occurred on a Friday on or about 4/10/2020. S2 told R1 "to be quiet when the resident said that she was cold." S2 said that R1 that she was annoying. Resident 1 was also interviewed via Facetime.

LPA Chin spoke to Maria Domingo, Executive Director over the telephone that S2 was placed on administrative leave and not working the facility at this time.

No deficiency cited this review.

An exit teleconference was conducted with Maria Domingo, Executive Director and LPA Chin discussed and read this report. A copy of this report will be provided via email; and Ms. Domingo agreed to confirm the receipt of the document.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2020
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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