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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005351
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:18:35 PM


Document Has Been Signed on 10/13/2022 02:18 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:FOUDIL MANADIFACILITY TYPE:
740
ADDRESS:27783 CENTER DRIVETELEPHONE:
(949) 364-6210
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:150CENSUS: 94DATE:
10/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Foudil ManadiTIME COMPLETED:
02:40 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) Kimberly Lyman made an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPA was greeted and granted entry into the facility by Executive Director Foudil Manadi and explained the reason for the visit.

Incident report dated 10/08/2022 indicated Resident 1 was observed by staff exiting the back door of the memory care unit. Resident was redirected back into the facility with no adverse affects. Physician report dated 07/25/2022 indicates resident is diagnosed with Dementia and has wandering tendencies. LPA spoke with resident during the visit who verbalized the resident likes to walk around. R1 appeared happy and well taken care of. LPA consulted with management team regarding keeping resident engaged to prevent any additional incidents.

Incident report dated 10/11/2022 indicated R2 was agitated and slapped R3 on the left side of the face. Staff intervened and the residents were separated. No injuries noted besides a red mark on R3's face. This is the first incident of aggression from R2. Per physician report dated 06/28/2022, R2 is diagnosed with Dementia with no inappropriate behavior. LPA met with both residents during the visit and both spoke with LPA and appeared happy and well taken care of.

LPA toured the memory care unit during the visit and observed multiple staff and residents participating in activities. No further action required.



No deficiencies noted during today's visit. 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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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 1