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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 07/02/2021
Date Signed: 07/02/2021 12:40:37 PM

Document Has Been Signed on 07/02/2021 12:40 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
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: 130DATE:
07/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Ana KunzTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit in conjunction with complaint visit 22-AS-20210629141449. LPA met with Chief Executive Officer (CEO) Ana Kunz and explained the reason for the visit. Administrator Patty Osuna and Ombudsman Lan Tran were present as well.

During the course of the complaint visit, LPA observed no incident report was submitted for Resident 1's diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA) and hospitalization. Per interviews conducted, there was conversation between hospital, facility, and Ombudsman on the resident returning to the facility with a positive diagnosis. LPA Lyman was not advised regarding the resident's health condition until complaint #22-AS-20210629141449 was filed.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with CEO Kunz and a copy of the report was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2021
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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Document Has Been Signed on 07/02/2021 12:40 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/02/2021 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WESTMINSTER VILLA
FACILITY NUMBER: 306004795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
87211(a)(1)

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events....This req is not being met:
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Licensee to provide training on reporting requirements to management team and forward proof to LPA by POC due date.
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Based on observation and interview, Licensee failed to ensure R1's MRSA diagnosis was reported to Licensing. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021


LIC809 (FAS) - (06/04)
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