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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 06/18/2021
Date Signed: 06/18/2021 10:49:34 AM

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:
06/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Viola Kaake, Reminiscence CoordinatorTIME COMPLETED:
10:58 AM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Jim August to follow up on an incident reported to Community Care Licensing. LPA met with Reminiscence Coordinator Viola Kaake and explained the purpose of today’s visit. Incident was self reported on 06/09/2021 regarding resident 1 (R1’s) incident on 06/08/2021.

It was reported that staff 1 (S1) erroneously missed a dose of medication for R1 on 6/8/2021. The medication was Carbidopa and Synthroid. This was a single occurrence. R1 was noted to be ok and the facility notified family and her PCP. S1 was pulled off duty and will be taking additional classes, in service training and one-on-one training at the facility for observations.

LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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