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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 06/13/2022
Date Signed: 06/13/2022 01:07:50 PM


Document Has Been Signed on 06/13/2022 01:07 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: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: 66DATE:
06/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maria Domingo, Executive Director & Erica Colmenares, Resident Care DirectorTIME COMPLETED:
01:30 PM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA), Kathrina Chin to follow up on a medication error to Community Care Licensing on 5/19/2022. LPA arrived at facility and met with Maria Domingo, Executive Director and explained the nature of the visit.

Maria Domingo, Executive Director stated that resident 1's medications were not "activated" on the E-mar system. Resident had just moved into the community on the evening of May 17, 2022. The staff were then unaware that resident's medications was to be given. Staff did not give resident 1's medications for two days, May 18, 2022 and May 19, 2022. Staff reported the missed medications to the resident's primary physician. No negative effects noted. Staff continued to observe resident for any negative outcome.



At this time, based on the information available, there are no deficiencies being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview interview was conducted and a copy of this report provided to the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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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