306005290-11-19-2020-22-AS-CTRD-BVHVXA-20201119154912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005290
Report Date: 11/19/2020
Date Signed: 11/19/2020 03:51:06 PM

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:	ATRIA PARK OF WOODBRIDGE		FACILITY NUMBER:	306005290
ADMINISTRATOR:	TAMMIE SAMPEDRO		FACILITY TYPE:	740
ADDRESS:	1 WITHERSPOON		TELEPHONE:	9496548500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	180	CENSUS: 75	DATE:	11/19/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Tammie San Pedro, Vice President of Operations Chad McDonald, National Director of Care Services Jen Johnson and Project Director of Operations Jordan Pope		TIME COMPLETED:	01:00 PM

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Licensing Program Analysts (LPAs) Patricia Velazquez and Criss Trinidad conducted an announced Pre-Licensing visit via phone FaceTime virtual technology to Atria Park of Woodbridge due to the COVID-19 Pandemic and precautionary measures. LPAs conducted the visit with Executive Director Tammie San Pedro, Vice President of Operations Chad McDonald, National Director of Care Services Jen Johnson and Project Director of Operations Jordan Pope. The purpose of this Case Management visit was to evaluate the facility’s Memory Care Unit. LPAs Trinidad and Velazquez confirmed with Executive Director Tammie Sampedro that the facility will be advertising Dementia Care and the regulations have been incorporated into their Plan of Operation. The Dementia Plan of Operation was approved by the Central Applications Bureau.

LPAs Trinidad and Velazquez along with Tammie Sampedro, Chad McDonald, Jen Johnson and Jordan Pope observed the following:

Structure:

The Dementia Memory Care Unit consists of 21 resident rooms each with their own bathroom that will accommodate up to 25 residents. The rooms included a 1-bedroom apartment, 3 Companion/Friendship suites and 17 Studios. The common areas consist of a living room, activities center, dining room, and medication room. There is an interior courtyard with planters and several shaded seating areas for residents.

Bedrooms Residents:
All bedrooms accommodate non-ambulatory residents. Emergency lighting is powered by a backup generator and nightlights were present in the Memory Care Unit. The resident bedrooms will accommodate the residents' furnishings.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

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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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: ATRIA PARK OF WOODBRIDGE	FACILITY NUMBER: 306005290
	VISIT DATE: 11/19/2020

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Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars were present as a well as a non-skid surface.

Linens and Hygiene Supplies:

Adequate supply of linens will be stored in the laundry room. Hygiene supplies will be located in a cabinet in the bathroom.

Smoke and Carbon Monoxide Detectors:

Smoke and carbon monoxide detector alert systems were interconnected and tested by the Fire Marshall on 05/10/2020 and found operational.

Fire Extinguisher:
There were 3 fire extinguishers throughout the Memory Care Unit and were serviced on 08/21/2020.

Fire Clearance:
Initially approved on 05/01/2020. A second approval on 11/10/2020 included 5 Delayed Egress doors in the first floor Memory Care Unit. The delayed egress doors were tested and found to be in operating condition.

Toxins and Sharps:
The cleaning supplies will be locked and stored in a locked cabinet. The knives and other sharp items will be stored in a locked kitchen cabinet drawer.

Water Temperature:
The water temperature was measured in 10 resident rooms and was in the range of 109.9 - 110.8 degrees Fahrenheit.

Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored in a locked closet located in the kitchen. Medication will be stored in a locked closet located in the kitchen.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

LIC809 (FAS) - (06/04)

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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: ATRIA PARK OF WOODBRIDGE	FACILITY NUMBER: 306005290
	VISIT DATE: 11/19/2020

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Reading Material, Games, Equipment, & Materials:
The facility had materials, games, and equipment present in the facility that commensurate with their dementia plan of operation.

The items reviewed during this visit are in compliance. The inspection of the Memory Care Unit is complete. The new license will be granted upon completion of a final review and approval from the Licensing Program Manager.

An exit phone interview was conducted with Executive Director Tammie Sampedro and a copy of this report was signed by LPA Criss Trinidad. This report will be sent via email to Tammie Sampedro who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Tammie Sampedro agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

LIC809 (FAS) - (06/04)

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