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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005546
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:02:16 PM


Document Has Been Signed on 07/16/2024 03:02 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:REATA GLEN ORANGE COUNTY CCRC LLCFACILITY NUMBER:
306005546
ADMINISTRATOR:KELLY CONKFACILITY TYPE:
741
ADDRESS:2 LAS ESTRELLAS LOOPTELEPHONE:
(949) 545-2250
CITY:RANCHO MISSION VIEJOSTATE: CAZIP CODE:
92694
CAPACITY:840CENSUS: 642DATE:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kelly Conk and Marirose KendleTIME COMPLETED:
03:25 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 conducted an unannounced case management visit to follow up on a death report received by the department on 07/12/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Death report dated 07/07/2024 indicated Resident 1 (R1) was found on floor by husband around 8:48 AM. Husband called facility safety unit who responded within 2 minutes. 911 was called and compressions were started on resident. OC Fire and Sheriff responded and took over CPR. Resident was declared deceased at 9:18 AM. OC SD DR#24-022499 and Coroner Report #24-03692. Resident was independent of services. Per facility protocol, Resident checked in with facility around 6:45 AM on 07/07/2024. Physician report dated 10/22/2020 indicated resident is diagnosed with Hypertensive Disorder and Appraisal Needs and Services indicates chronic Atrial Fibrillation.
Facility to forward a copy of the death certificate upon receipt from family.









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: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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