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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004761
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:40:18 PM


Document Has Been Signed on 11/27/2023 03:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR:LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 74DATE:
11/27/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator, Lauren ChonTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a health and safety visit of residents in care for the purpose of following up on incident which occurred late evening on 11/22/23. Orange Adult and Senior Care Regional Office received a phone message that facility had to shut down water and power due to a pipe bursting. Upon contacting Administrator Lauren Chon it was discovered that a accident occurred where a car ran up on street curb hitting facility sign and sides of facility building.

During visit LPA Tirre toured facility with Administrator Lauren Chon. LPA observed first and second floor hallways resident rooms, kitchen dining rooms, common area activity rooms and resident common areas. LPA observed facility to have working power, water and food supply. LPA observed residents in common areas playing bingo, watching TV and relaxing inside bedrooms. Residents observed were neatly groomed in appearance, and appeared alert as evidenced by greeting LPA. During visit LPA conducted interview with Resident 1, who was one of the residents impacted by incident. R1 confirmed they were healthy, safe and not harmed during incident. LPA also talked to resident 2 whose room was also impacted by incident. Resident 2 confirmed they were not harmed, was evacuated and relocated to another room. Resident 2 confirmed they feel safe in facility. LPA was unable to speak to other two residents impacted by incident due to one being out of facility and other resident was preoccupied with activities.

Rooms impacted were taped with notices of Limited Entry Signs stating off limits to unauthorized Personnel. LPA did not observe any additional health and safety risks.

Based on today's inspection, no deficiencies were observed at this time in the areas evaluated. This report was reviewed with Administrator and copy of report was left at facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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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