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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003060
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:29:41 PM


Document Has Been Signed on 10/25/2023 02:29 PM - It Cannot Be Edited

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:WEST GLENN MANORFACILITY NUMBER:
306003060
ADMINISTRATOR:ROSARIO NAZARENOFACILITY TYPE:
740
ADDRESS:7242 WESTMINSTER BLVD.TELEPHONE:
(714) 898-2131
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:98CENSUS: 87DATE:
10/25/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Rosario Nazareno- Licensee/AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after issuing a citation during a Case Management-Deficiencies visit conducted on today's date. LPA explained the reason for the Plan of Correction (POC) visit.

*Deficiency cited under Title 22 Regulation 87211(a)(1) was pertaining to a written report sent to the licensing agency within seven days of any incidents. LPA verified that the incident report regarding Resident #1 (R1)'s medication error was reported to the Department during today's visit, therefore the Licensee/Administrator has complied with the POC.

A copy of the Letter of Deficiency Citations Cleared form was provided during today's date.

Licensee has been advised to maintain compliance in the item previously cited.

An exit interview was conducted with Licensee/Administrator Rosario Nazareno, and a copy of this report including the LIC811 and the Letter of Deficiency Citations Cleared were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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