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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004751
Report Date: 04/23/2021
Date Signed: 04/23/2021 11:12:36 AM

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:FULLERTON GARDENSFACILITY NUMBER:
306004751
ADMINISTRATOR:SHERYL MCCASKILLFACILITY TYPE:
740
ADDRESS:1510 E. COMMONWEALTH AVENUETELEPHONE:
(714) 441-2636
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:72CENSUS: 23DATE:
04/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Sheryl McCaskillTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Sean Haddad conducted an unannounced Case Management inspection via tele-visit due to COVID-19 and for precautionary measures for the purpose of following up on the following incident that was self reported by the facility . LPA met with Administrator (AD) Sheryl McCaskill and discussed purpose of the tele-visit.

It was reported that on 4/10/21 Resident #1 (R1) was observed with their legs hanging off their bed. A caregiver assisted R1 with placing their legs back on the bed. 5 minutes later, a caregiver was across the hall and heard a noise, ran to R1's room, and found R1 on the floor. A body check was done and revealed a bump on R1's head, with R1 alert and oriented. Facility staff called 911 and informed R1's family and doctor. R1 was hospitalized with a head injury.

During today's inspection, LPA inspected R1's room and observed no health and safety hazards. LPA conducted a health and safety check on R1, found R1 to be in good health with the injury healed, and observed no health and safety issues. LPA interviewed AD who stated R1 returned to the facility from the hospital on 4/16/21, R1 had a history of falls before being admitted, and this is R1's second fall at the facility (the first resulted in no injury). R1's current fall precautions include a soft mat on the floor and checks every 1-2 hours while R1 is in their room. AD considered 1 on 1 supervision, but determined that is not yet needed. LPA determined that the facility properly handled the above situation.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with AD. This report along with the LIC811 will be emailed and an electronic email read receipt confirms receipt of the report. AD agrees to sign the report and email it back to LPA.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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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