<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:10:15 PM

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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Ana Kunz and Patty OsunaTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Chief Executive Officer Ana Kunz and explained the reason for the visit. Administrator Patty Osuna was present as well. Facility is a two story building with capacity for 200 residents.

At 10:15 AM, LPA toured the facility with Administrator Patty Osuna, Maintenance Alejandro Delfin, and Caregiver Supervisor Monserrat Passilas. Facility has 130 residents in care during today's visit. LPA observed residents relaxing outside or in their rooms. LPA spoke with varied residents who expressed satisfaction with the facility. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet as well as temperature taking and screening. Facility takes resident and staff temperatures daily and documents. LPA observed screening documents. Facility has covid precaution postings as well as all required department postings. LPA observed multiple sanitizing stations throughout the facility. Resident rooms have all the required elements. LPA reviewed the mitigation plan. LPA observed ample emergency food and water as well as first aid kit. LPA observed a shaded outside area for smoking and a visitation area in the front of the facility. Fire extinguishers are mounted and charged and located throughout the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation.


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: 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)
Page: 1 of 1