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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004582
Report Date: 07/05/2022
Date Signed: 07/05/2022 01:22:26 PM


Document Has Been Signed on 07/05/2022 01:22 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:ROBERT FIORENTINO IIFACILITY TYPE:
740
ADDRESS:1640 & 1650 MONROVIA AVETELEPHONE:
(949) 629-2100
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:430CENSUS: 306DATE:
07/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Bob Fiorentino Senior Executive DirectorTIME COMPLETED:
01:35 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) Bob Fiorentino. The purpose of today's Case Management visit was to follow-up on an Incident and Death Report received in the Orange Regional Office on June 24, 2022 regarding Resident (R) #1.


On today's visit LPA Velazquez conducted interviews with staff. LPA Velazquez reviewed R1's file and was provided with copies of pertinent documentation from R1's file. LPA Velazquez reviewed Title 22 Regulation Section 87465 - Incidental Medical and Dental Care and Section 87469 - Advanced Directives and Requests Regarding Resuscitative Measures with facility staff. LPA Velazquez provided copies of these regulations so that facility may conduct an in-service staff training regarding these regulations. LPA Velazquez will be provided with proof of staff training by July 19, 2022.




There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Senior Executive Director Bob Fiorentino and a copy of this report along with the LIC 811s were 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: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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