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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 05/12/2021
Date Signed: 05/12/2021 10:47:58 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:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:ANA KUNZFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: 129DATE:
05/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ana KunzTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report submitted to Community Care Licensing (CCL) on 05/11/2021. LPA met with Administrator Ana Kunz and explained the reason for the visit.

Incident report dated 05/11/2021 indicated DPOA for Resident 1 (R1) reported that R1 had advised of consensual intercourse with Staff 1. During the visit, LPA interviewed staff and R1 as well as reviewed video surveillance for 04/25-04/26/2021. LPA reviewed and obtained documentation such as physician report and contact information for witnesses. LPA observed R1 appears clean, taken care of and verbalizes feeling safe at the facility. The investigation remains ongoing.



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: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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