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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004582
Report Date: 04/19/2022
Date Signed: 04/19/2022 03:55:18 PM


Document Has Been Signed on 04/19/2022 03:55 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:VIVANTE ON THE COASTFACILITY NUMBER:
306004582
ADMINISTRATOR:KORNMANN, JENNIFERFACILITY TYPE:
740
ADDRESS:1640 & 1650 MONROVIA AVETELEPHONE:
(949) 629-2100
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:430CENSUS: 278DATE:
04/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Jennifer Kornmann - Sr. Executive DirectorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Vivante on the Coast. LPA Velazquez was allowed entry into the facility and met with Senior Executive Director (SED) Jennifer Kornmann. The purpose of today's Case Management visit was to follow-up on an Incident Report received in the Orange Regional Office on April 11, 2022 regarding Resident (R) #1.


On today's visit LPA Velazquez conducted interviews with staff and R1. LPA Velazquez was provided with copies of pertinent documentation from R1's file as well as from Staff (S) #2.





There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Senior Executive Director Jennifer Kornmann and a copy of this report along with the LIC 811 was provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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