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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006242
Report Date: 10/04/2024
Date Signed: 10/04/2024 02:31:55 PM

Document Has Been Signed on 10/04/2024 02:31 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAPRIANAFACILITY NUMBER:
306006242
ADMINISTRATOR/
DIRECTOR:		REYNOLDS, TONYAFACILITY TYPE:
741
ADDRESS:460 LA FLORESTA DRIVETELEPHONE:
(714) 985-5500
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 200CENSUS: 94DATE:
10/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ashley Lee, Business Office Director (BOD)TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit regarding an Incident Report received in our office on October 4, 2024. LPA was greeted and granted entry by the Concierge. The facility's current census is ninety-four residents.

The purpose of the visit is to follow-up on a Death Report received in our office. LPA requested Resident #1 (R1)'s: Identification Form, Physician's Report, Needs and Services Plan/ Appraisal, Pre-appraisal, Progress Notes as well as copies of the Staffing schedule for October 1, 2024.

LPA spoke with Lizette Flores, Health Services Director (HSD) regarding the incident and the chronological order of events.

An exit interview was conducted with Ashley Lee, BOD and a copy of this report and LIC 858 were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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