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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005796
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:51:41 PM


Document Has Been Signed on 12/14/2022 12:51 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ACTIVCARE ORANGEFACILITY NUMBER:
306005796
ADMINISTRATOR:LEDESMA, ELVAFACILITY TYPE:
740
ADDRESS:2629 E. CHAPMAN AVENUETELEPHONE:
(714) 215-9944
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:72CENSUS: 21DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Vanessa ValenciaTIME COMPLETED:
01:05 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez conducted an unannounced case management visit to follow up on an SOC 341 dated 12/05/2022. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

SOC 341 indicated Resident 1 (R1) reported being soiled over night as well as being denied assistance by Staff (S1). After the incident was reported, R1 was assessed and had no injuries. Facility investigated the incident and S1 was suspended pending investigation. S1 was terminated effective 12/12/2022.


During the visit, LPAs toured the facility, interviewed Staff and attempted to interviewed R1 and facility Residents LPAs were unable to interview R1 due to the dementia diagnosis. Per physician report dated 04/28/2022, Resident is diagnosed with Lewy Body Dementia, Parkinson's disease and hearing loss. LPAs observed Residents eating lunch in the dining room and appeared well taken care of.
LPAs reviewed and obtained pertinent documentation such as physician report, Staff records and Staff statements regarding the incident.







No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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