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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005351
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:30:39 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:LA VIDA AT MISSION VIEJOFACILITY NUMBER:
306005351
ADMINISTRATOR:JUSTINE ORTIZFACILITY TYPE:
740
ADDRESS:27783 CENTER DRIVETELEPHONE:
(949) 364-6210
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:150CENSUS: 97DATE:
11/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Danica CoronelTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report/ SOC 341 submitted to Community Care Licensing on 10/07/2021. LPA was greeted and granted entry into the facility by Director of Assisted Living Danica Coronel and explained the reason for the visit.

Incident report dated 10/06/2021 indicated Resident 1 (R1) had poked R2 with the residents cane and called the resident "Princess Leah." R1 indicated just joking around. Resident assessed and no injuries noted. During the visit, LPA interviewed both residents. Both residents appear to be happy and well taken care of. Facility spoke with R1 and the resident denied any intent to harm stating the resident was just joking. Facility continues to monitor both residents.




Exit interview conducted and a copy of this report will be emailed due to technical difficulties.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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