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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 11/18/2020
Date Signed: 11/19/2020 05:58:25 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: 70DATE:
11/18/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Maria Domingo, Executive DirectorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone as a follow up to a case management- incident via telephone due to COVID-19 and for pre-cautionary measures. LPA Chin identified herself and spoke to Maria Domingo, Executive Director.

LPA, Kathrina Chin spoke to Maria Domingo, Executive Director regarding resident #1(R1) over the telephone today. LPA explained that the purpose of this tele-visit is to discuss the self-reported incident which occurred on 11/6/2020. R 1 stated that "he would rather die than be with his wife." R 1 and his wife both live at the facility. Ms. Domingo explained that resident denied wanting to kill himself and refused to go to the Emergency Room. R1 was cleared medically and remain at the facility.

No deficiency cited this review as per Title 22 of the California Code of Regulations.

An exit interview was conducted with Administrator via telephone and a copy of this report was provided to Administrator via email. Maria Domingo agreed to confirm the receipt of the document, review the report and return a signed copy.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020
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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