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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 11/15/2021
Date Signed: 11/15/2021 11:16:39 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: 74DATE:
11/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria Domingo, Executive DirectorTIME COMPLETED:
11:45 AM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA), Kathrina Chin to follow up on a GI outbreak reported to Community Care Licensing on 11/10/2021. LPA arrived at facility and met with Maria Domingo, Executive Director and explained the nature of the visit.

Maria Domingo, Executive Director reported that the infectious GI virus started on 10/7/2021 and reported to Orange County Public Health and the licensing office on 11/10/2021. On November 10, 2021, Ms. Domingo stated that Public Health Department suspect that it is Norovirus. The memory care unit was placed on quarantine and all meals were delivered to their rooms. Maria Domingo stated that visitors are discouraged in the memory care unit. As of today, 11/15/2021, there are a total of 7 staff members and 11 residents of having GI symptoms. Ms. Domingo stated that she trained all the staff in Memory Care on infection control. The Memory Care Unit is cleaned three times a day.



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: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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