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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005226
Report Date: 06/17/2020
Date Signed: 06/17/2020 11:35:31 AM

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:ARBOR PALMS OF ANAHEIMFACILITY NUMBER:
306005226
ADMINISTRATOR:NANCY RODRIGEZFACILITY TYPE:
740
ADDRESS:3411 W BALL RDTELEPHONE:
(714) 821-9660
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:130CENSUS: 117DATE:
06/17/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Executive Director Nancy RodriguezTIME COMPLETED:
11:15 AM
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As a precautionary measure during the Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin made an unannounced case management visit to this facility via video teleconference with Executive Director (ED) Nancy Rodriguez. LPA stated the purpose of this visit was to discuss the deficiency found during investigation for complaint no. 22-AS-20200225161158.

Based on file review of documents received during the complaint investigation, on January 7, 2020 Resident 1 had unobserved fall. R1 was checked; and responsible party and physician were informed. Based on file review Community Care Licensing Division did not receive any written report about the incident. Per Executive Director, the incident was documented in the facility internal report; and responsible party and physician were informed; and condition of the resident was closely monitored after the incident with no further untoward events.

LPA Marin discussed with ED the California Code of Regulations (CCR) Section 87211 Reporting Requirements.

LPA Marin conducted an exit interview, and read this report to ED Rodriguez. LPA will provide copies of this report with Advisory Notes, and of the CCR section discussed via email. ED agreed to acknowledge their receipt.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
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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