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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:45:44 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: 127DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Alexis Jones, Care CoordinatorTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch made an unannounced case management visit to follow up on an incident report submitted to Community Care Licensing (CCL) on 11/09/2021. LPAs met with Care Coordinator Alexis Jones and explained the reason for the visit.

Incident report dated 11/09/2021 indicated that at approximately 1:30pm on 11/03/2021 Resident 1 (R1) stated he was leaving to the 99 cent store. At around 5:30pm caregivers notified he was not present within the facility. Police was called and a missing person report was filed at approximately 7:30pm.

LPAs reviewed R1 medical file and physician's report, dated 08/25/2021. Mental Condition items indicate that R1 is both ambulatory and able to leave the facility unassisted. During a physical tour of the facility, R1 was observed to be relaxing in their own bedroom.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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