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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:28:19 PM


Document Has Been Signed on 12/12/2023 02:28 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: 174DATE:
12/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darlene Lindley - AdministratorTIME COMPLETED:
02:45 PM
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) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20200814090028.

During the complaint investigation mentioned above, it was discovered the facility had an outbreak of scabies in 2020. During interviews, 4 staff members and 1 resident confirmed the scabies outbreak. According to the staff members the outbreak lasted about two/three weeks. Resident’s who had scabies were treated with a cream, isolated, rooms were sanitized, and clothing was washed separately.

After reviewing incident reports submitted to the Orange County Adult and Senior Care Program Regional Office, it was discovered the scabies outbreak in 2020 was not reported to the Department as required.

As a result of today’s Case Management visit, deficiencies will be cited.

An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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 12/12/2023 02:28 PM - 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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87211(a)(2)

1
2
3
4
5
6
7
Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (2) Occurrences, such as epidemic outbreaks,...or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours... to the licensing agency and to the local health officer when appropriate.
1
2
3
4
5
6
7
Administrator Lindley will review Regulation Section 87211 and email a statement of understanding and a plan of action that will prevent a failure to report in the future. Administrator Lindley will include who will be responsible for submitting incident reports and who will be the back up incase the designated personable is not available. The POC is due no later than Tuesday, December 19, 2023 at 1:00PM.
8
9
10
11
12
13
14
This requirement is not being met as evidenced by the outbreak of scabies in 2020. The outbreak was confirmed by staff and a resident. After reviewing incident reports submitted to the Regional Office it was discovered the scabies outbreak was not reported as required.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2