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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006204
Report Date: 05/09/2023
Date Signed: 05/16/2023 03:03:02 PM


Document Has Been Signed on 05/16/2023 03:03 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:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:130CENSUS: 65DATE:
05/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Alma EspinalTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20230414121958. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA reviewed the admission agreement for Resident 1 (R1). R1 admitted into the facility via Adult Protective Services on 03/09/2023. While resident was acclimating to the new environment, admission agreement was not signed until 04/17/2023. Facility indicates inadvertent error with the signing of the admission agreement.










Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was emailed to Administrator as well as Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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Document Has Been Signed on 05/16/2023 03:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2023
Section Cited
CCR
87507(c)

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Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission...This requirement is not being met as evidenced by:
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Licensee to provide a written statement of understanding of the regulation and forward proof to LPA by POC due date.
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Based on record review and interview conducted, Licensee failed to ensure admission agreement was signed within seven days of admission. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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