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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 02/15/2024
Date Signed: 02/15/2024 12:47:00 PM


Document Has Been Signed on 02/15/2024 12:47 PM - 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:FULLERTON VILLAFACILITY NUMBER:
306004839
ADMINISTRATOR:DARLENE LINDLEYFACILITY TYPE:
740
ADDRESS:2441 W. ORANGETHORPE AVE.TELEPHONE:
(714) 992-5380
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:197CENSUS: 172DATE:
02/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Jae-Wan Rim, Assistant AdministratorTIME COMPLETED:
01:00 PM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to conduct 10 day visit for complaint control #22-AS-20240207092654. LPA Quiroz met with Assistant Administrator Jae-Wan Rim and discussed purpose of today's visit.

On or about 12:05pm, while conducting facility inspection visit on first floor in Activity room, LPA Quiroz observed open ceiling with trash bin observed to be placed due to leaking ceiling. This was verified with Assistant Administrator Jae-Wan Rim who indicated "Yesterday, we thought it was a fire sprinkler drip so we called our fire consultants who then opened the ceiling and ruled out fire sprinkler issue and said it was a plumbing issue, but they had to open up the ceiling to inspect it and now our maintenance director is working on it."

LPA Quiroz provided consultation on CCR 87211: Reporting Requirements

(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.


Administrator Assistant Rim indicated understanding CCR 87211: Reporting Requirements indicating he informed CCL during today's visit and will follow up with assigned LPA during process and repair of ceiling in Activity room on 1st floor.

Technical assistance provided during today's visit. (See LIC 9102-TA)

An exit interview was conducted, and a copy of this report, LIC 9102-TA were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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