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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005940
Report Date: 10/17/2022
Date Signed: 10/17/2022 05:01:36 PM


Document Has Been Signed on 10/17/2022 05:01 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:ADULT CARE OC ACROPOLISFACILITY NUMBER:
306005940
ADMINISTRATOR:SZALONEK, FEFACILITY TYPE:
740
ADDRESS:24685 ACROPOLIS DRIVETELEPHONE:
(626) 864-9955
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
10/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Fe Szalonek, AdministratorTIME COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit following up on two incident reports submitted to the Department on 10/14/2022 regarding fall incidents involving resident R1. LPA was greeted and granted entry by caregiving staff after introducing himself and explaining the purpose of the visit. Administrator Fe Szalonek was notified by telephone and arrived later to assist with the visit.

LPA was initially routed to another facility (New Home Senior Care 4 - licensing #306005924) operated by the same licensee but was informed resident R1 was actually being cared for at Adult Care OC Acropolis instead.

LPA observed the residents in care sharing dinner in the facility's common area.

The reports initially submitted to the Department made no mention of medical attention being sought as a result of either incidents. LPA requested additional information from administrator after her arrival at the facility. On both instances, the resident's Responsible Party was immediately notified and advised to seek medical attention. Upon initial reticence from the resident's daughter on the second instance, the Administrator stated that she would seek medical attention herself if the RP declined to do so. Resident R1 was taken to urgent care and diagnosed with a Urinary Tract Infection. A follow-up visit was scheduled on 10/17/2022 with no new orders resulting from the visit. LPA was presented with documentation of both days in the facility log. Additionally, Administrator has provided staff with in-service training on fall behaviors and appropriate incident documentation.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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