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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006006
Report Date: 08/22/2024
Date Signed: 08/22/2024 08:37:34 AM


Document Has Been Signed on 08/22/2024 08:37 AM - 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:HEYDAY SENIOR LIVING OF COSTA MESAFACILITY NUMBER:
306006006
ADMINISTRATOR:ALIM, REA BADILLOFACILITY TYPE:
740
ADDRESS:2750 LORENZO AVETELEPHONE:
(562) 303-0130
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:21 AM
MET WITH:Raissa MagnoTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report received by Community Care Licensing on 08/20/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Death report dated 08/18/2024 indicated that on 08/13/2024, Resident 1 (R1) started coughing at lunch. Staff checked the airway and called 911. Resident was having difficulty breathing. Paramedics responded and determined there was nothing blocking the airway and requested to see the "Do not resuscitate" (DNR) paperwork. Resuscitation was not attempted due to the DNR on file. Resident passed at 12:19 PM. Per physician report dated 07/28/2024, R1 has a history of Hypertension and Hyperlipidemia.

LPA toured the facility during the visit and observed the following: Facility appears clean, safe and sanitary. Residents were observed eating breakfast and relaxing in the living room. No health and safety concerns noted during the 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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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