<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002644
Report Date: 07/24/2020
Date Signed: 07/24/2020 05:27:29 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 OF MISSION VIEJOFACILITY NUMBER:
306002644
ADMINISTRATOR:SOUZA, THAIS ANDRADEFACILITY TYPE:
740
ADDRESS:26151 COUNTY CLUB DRTELEPHONE:
(949) 582-2010
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:110CENSUS: 78DATE:
07/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Resident Care Director (RCD) Roana CruzTIME COMPLETED:
03:30 PM
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
At 2:00 PM Licensing Program Analyst (LPA), Mike Barrett, conducted a Case Management tele-visit with this facility, due to COVID-19 and precautionary measures, and spoke with Resident Care Director (RCD), Roana Cruz, and stated thee purpose for the visit, which was to follow up on a self reported incident received in the department on 7/23/2020.

The facility self-reported that Resident #1 (R1) and Resident #2 (R2) were found away from the facility by Staff on 7/19/20. It was reported that R1 and R2 were last seen in the facility at approximately 1:30 PM and were located by staff off-site and brought back to the facility safely at 2:09 PM. R1 and R2 were evaluated upon return with no injuries and incident was reported to their responsible parties and primary care physicians. R1 and R2 were moved into the memory care unit of the facility for closer monitoring and RCD Cruz reported that there have not been any further incidents or exit attempts by either of the residents. LPA Barrett was informed by RCD Cruz that an investigation is in process to determine how the residents were able to leave that facility which is being conducted by the Executive Director, who was not in the facility at the time of this tele-visit.

Due to more needing more information this investigation will be completed at another date and time.

No citations were issued during this visit.

An exit interview was conducted with RCD Roana Cruz and a copy of this report, along with LIC 811 (confidential names list) was provided via email and an electronic read receipt confirms the delivery of this report.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
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