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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 07/26/2023
Date Signed: 07/26/2023 10:12:51 AM


Document Has Been Signed on 07/26/2023 10:12 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:
07/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Patty OsunaTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez and made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on 7/25/2023. LPA met with Administrator (AD) Patty Osuna and Assistant Administrator (AAD) Alexis Jones and explained the reason for the visit.

Incident report dated 7/25/2023 indicated that on 7/24/2023 Resident 1 (R1) had left the facility and had not returned by 10 p.m. that evening. A missing person’s report was filed with the Garden Grove Police Department. R1 is able to leave the facility unassisted per Physician Report (LIC602) dated 5/11/2023.

During interviews, AAD and AD reported R1 had not returned, and they did not have an update regarding R1’s whereabouts. AAD provided LPA with a copy of emergency contact information for R1, Garden Grove Police Department’s missing person’s report, and resident sign-out log for 7/24/2023.

At 9:30 a.m. as LPA conducted records review of documents provided AAD reported R1 had just arrived and was in the lobby of the facility. LPA interviewed R1 who stated they had been at a friend’s house and stated they had not called the facility to inform them because they did not know facility’s phone number. Per R1, they did not inform facility staff they were leaving on 7/24/2023 to stay with their friend because “it’s none of their business.”

Based on today’s observations no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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