306002568-9-10-2021-22-AS-RMAZ-C6QPDF-20210910111328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:13:31 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 LINDA		FACILITY NUMBER:	306002568
ADMINISTRATOR:	MARIA DOMINGO		FACILITY TYPE:	740
ADDRESS:	4792 LAKEVIEW AVE		TELEPHONE:	(714) 693-5368
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	93	CENSUS: 74	DATE:	09/10/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Maria Domingo		TIME COMPLETED:	11:25 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on a death reported to Community Care Licensing on 08/31/2021 for the death of a resident on 08/28/2021. LPA arrived at facility and informed receptionist of visit. LPA met with Maria Domingo, Administrator and explained the nature of the visit.

During the visit LPA obtained copies of the following documents pertaining to resident (R1) 1: Move in record, visit summary from ER visit of 08/26/2021, physician’s report, home health/hospice visit reports, case sheet, plan of care prior and revised, medication list, Resident agreement, and certificate of death.

Based on the information reviewed R1 had an unwitnessed fall on 08/26/2021. R1 resided in the memory care unit and was found lying supine on the floor at the head of the bed with walker next to resident. Staff heard R1 calling for help and went in to check on R1. Staff immediately called 911 upon assessing R1. R1 was sent out to Placentia Linda Hospital immediately for evaluation. R1 was transferred back to facility on the same day with care plan management. LPA obtained a copy of the certified of death indicating immediate cause of death for R1. LPA advised Administrator that further information may be required at a later date.

LPA did not observe any immediate and/or safety risks in or out of the facility.

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.

This report is being reviewed with facility representatives and a copy provided to the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 1