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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:18:40 AM


Document Has Been Signed on 03/25/2022 11:18 AM - 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:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Patty Osuna- administor TIME COMPLETED:
11:38 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil made an unannounced visit to the facility to initiate a case management visit to follow up on an incident report submitted to Community Care Licensing. LPAs were greeted and granted entry into the facility by Administrator Patty Osuna and explained the reason for the visit.

Incident report dated 03/21/2022 indicated that at approximately 6:15 am on 03/21/2022 Resident 1 (R1) was not in the facility. Caregivers searched the facility and resident was not found. Police were called and a missing person report was filed at approximately 12:15pm. R1 returned to facility on 03/24/2022 and was sent out for a psych evaluation.

LPAs reviewed R1 physician's report, dated 05/14/2020 Mental Condition items indicate that R1 is both ambulatory and able to leave the facility unassisted.


LPAs spoke with licensee in regards to cancelled surety bond. Licensee showed proof of payment and will forward documents to LPA by 04/01/2022

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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