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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006189
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:01:09 PM


Document Has Been Signed on 11/17/2022 04:01 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:KAEGO'S RICHMAN GARDENSFACILITY NUMBER:
306006189
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:317 N. RICHMAN GARDENSTELEPHONE:
(213) 478-0460
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:26CENSUS: 16DATE:
11/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Rebecca RamosTIME COMPLETED:
04:15 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 11/14/22 regarding Resident #1 (R1) and Resident #2 (R2). LPA met with Staff #1 (S1) Rebecca Ramos and discussed the purpose of the inspection.

The incident report states that on 11/13/22, R1 attacked their roommate, R2, with a dresser drawer; R1 and R2 were immediately separated by facility staff; facility staff called 911 to request a 5150 evaluation; R2 was treated at a local hospital and returned a few hours later; the police took R1 to the county jail due to the nature of the incident; and R1’s family decided to remove R1 from the facility after the incident.

During today’s inspection, LPA conducted a health and safety check on R2 and observed that R2 had minor bruises but was otherwise in good health and was able to walk and LPA observed no health and safety issues. Long Term Care Ombudsman (LTCO) Jeannie Noh was present and interviewed R2 in Korean and stated that R2 stated that they are doing fine, but that R2 did not remember the incident. LPA interviewed S1 who reiterated the information provided in the incident report. LPA requested and reviewed a copy of R1’s resident file.

Facility representative was advised that at this time further investigation may be required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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