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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 03/18/2021
Date Signed: 03/26/2021 02:31:45 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: 65DATE:
03/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Maria Domingo, Executive DirectorTIME COMPLETED:
05:40 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 and FaceTime Application 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) and resident 2 (R2 LPA explained that the purpose of this virtual visit is to discuss an SOC 341 incident/report which occurred on March 16, 2021. Ms. Domingo explained that resident 1 (R1) along with his wife, resident 2 returned to the facility after going to a doctor's appointment. The wife told R1 that she needs to go the bathroom and will have to hurry back to their room. A facility employee found R1 unconscious and on the floor in the garage. The employee dialed 911 emergency personnel and two managers went down to the garage to check on R1. Resident was taken to UCI Medical Center and he continues to be at the hospital. Maria Domingo, ED reported that a Pace maker will be put in for R1.



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

An exit interview was conducted 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: 03/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021
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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