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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005351
Report Date: 04/11/2022
Date Signed: 04/11/2022 02:30:51 PM


Document Has Been Signed on 04/11/2022 02:30 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: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: 94DATE:
04/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Justine OrtizTIME COMPLETED:
02:50 PM
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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 04/05/2022. LPA was greeted and granted entry into the facility by Executive Director (ED) Justine Ortiz and explained the reason for the visit.

Incident report dated 04/04/2022 indicated Staff 1 (S1) had been yelling and aggressive with residents. The behavior had been reported by another caregiver. Caregiver reported to Enliven Director. ED immediately put S1 on suspension while investigating the incident. During the investigation, S1 resigned on 04/06/2022. No prior complaints lodged against S1 in eight years of employment at the facility. S1 has been disassociated from the facility in the Guardian system. All five residents indicated in the allegation reside in the memory care unit. All residents were assessed and no injuries noted.

During the visit, LPA toured the memory care unit. LPA observed all five residents relaxing in the common area of the facility. All residents appeared clean and safe. No health or safety concerns noted.





No further action required. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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