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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004582
Report Date:
04/26/2022
Date Signed:
04/26/2022 03:54:10 PM
Document Has Been Signed on
04/26/2022 03:54 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 COAST
FACILITY NUMBER:
306004582
ADMINISTRATOR:
KORNMANN, JENNIFER
FACILITY TYPE:
740
ADDRESS:
1640 & 1650 MONROVIA AVE
TELEPHONE:
(949) 629-2100
CITY:
COSTA MESA
STATE:
CA
ZIP CODE:
92627
CAPACITY:
430
CENSUS:
279
DATE:
04/26/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
01:25 PM
MET WITH:
Liana Foote - Senior Executive Director
Bob Fiorentino - Executive Director
TIME 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) Liana Foote. The purpose of today's Case Management visit was to follow-up on an Incident and Death Report provided to LPA Patricia Velazquez regarding Resident (R) #1.
On today's visit LPA Velazquez conducted interviews with staff. LPA Velazquez along with SED Liana Foote took a tour of R1's room. LPA Velazquez was provided with copies of pertinent documentation from R1's file.
There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Senior Executive Director Liana Foote and a copy of this report along with the LIC 811s were provided at the time of this visit.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(713) 334-2062
LICENSING EVALUATOR NAME:
Patricia Velazquez
TELEPHONE:
(949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE:
04/26/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/26/2022
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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