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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004823
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:25:56 AM

Document Has Been Signed on 11/10/2022 10:25 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:LEISURE TOWER II RESIDENTIAL CAREFACILITY NUMBER:
306004823
ADMINISTRATOR:NELSON PEREZFACILITY TYPE:
735
ADDRESS:608 E SYCAMORETELEPHONE:
(714) 321-1656
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 32CENSUS: 29DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nelson and Stephanie PerezTIME COMPLETED:
10:30 AM
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Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management visit. Upon arrival, LPA met with Administrator's Nelson and Stephanie Perez. The visit was conducted to follow-up on a death report submitted to the Licensing Office on 3/28/22.

On 3/27/22, Resident #1 left the facility and stated that she would be back at approximately 1:00pm and did not return. R1 would often leave the facility to visit a friend. Anaheim Police were notified as well as the Public Guardian's Office. On 3/28/22 the OC Coroner's Office contacted the facility to report that R1 was found deceased behind a nearby CVS. The cause of death was overdose.

No citations issued at this time.

An exit interview was conducted and a copy of this report was provided to Stephanie Perez.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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