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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 02/12/2024
Date Signed: 02/12/2024 10:26:31 AM


Document Has Been Signed on 02/12/2024 10:26 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: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:
02/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jae Wan RimTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management inspection to follow-up on an incident report received by Community Care Licensing on 2/05/2024. LPA met with Assistant Administrator (AAD) Jae Win Rim and explained the reason for the visit.

Incident report indicated that on 2/03/2024 at about 4:00 p.m., direct care staff informed front desk that Resident 1 (R1) was not in the dining area. Staff initiated search for R1. Camera footage was reviewed, and resident was seen leaving the facility at 3:22 p.m. Police were called and R1’s family was notified. Facility staff continued to try to locate R1 and found them at the nearest 4-way intersection.

During today’s visit, LPA interviewed AAD who confirmed details of the incident report. LPA was unable to interview R1, as they away at day program. LPA reviewed R1’s Physician Report (LIC602) dated 7/05/23, which indicates R1 has a dementia diagnosis and wandering behavior. LPA also reviewed Resident Appraisal (LIC603) dated 1/27/24, which indicates R1 needs special observation and 24-hour supervision.

Based on information gathered, LPA determined that staff did not adequately supervise R1, resulting in elopement from the facility; a Deficiency was cited on today’s date.

An exit interview conducted, and a copy of this report and appeal rights 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: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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 2


Document Has Been Signed on 02/12/2024 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FULLERTON VILLA
FACILITY NUMBER: 306004839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2024
Section Cited
HSC
1569.2(c)

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“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
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AAD stated resident has been placed on a 1:1 ratio to ensure 24-hour supervision and training regarding resident elopement would be conducted. AAD stated they would provide LPA with proof of training via email by POC.
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This requirement is not met as evidence by:

Based on information gathered, the facility did not assume responsibility for Resident’s wandering behavior, resulting in elopement from the facility, which poses an immediate safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2