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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006387
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:09:04 PM


Document Has Been Signed on 06/21/2024 04:09 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ANAHEIM VILLAFACILITY NUMBER:
306006387
ADMINISTRATOR:PARK, YOUNGFACILITY TYPE:
740
ADDRESS:3411 W BALL ROADTELEPHONE:
(714) 821-9660
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:210CENSUS: 60DATE:
06/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Darlene Lindley - AdministratorTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted this unannounced Case Management visit on today’s date. LPA arrived at facility was greeted and granted entry by staff. Nadia Chavelas. LPA met with Administrator (AD) Darlene Lindley and Assistant Administrator (AAD) Lea Wine. LPA explained the purpose of the inspection.

LPA stated that Community Care Licensing received an incident report from the facility on 6/6/2024 stating that a resident left the facility unassisted on 6/5/2024.

LPA reviewed the resident's Physician's Report. Based on record review, the Physician's Report indicates that the resident is unable to leave the facility unassisted. Based on the incident report and interview with Administrator, LPA determined that the resident left the facility unassisted. A deficiency is being issued on this day.

Based on Title 22, Dvision 6 of the California Code of Regulations, one deficiency is being issued. LPA reviewed this report with AD and AAD and provided this report, deficiency page and appeal rights to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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Document Has Been Signed on 06/21/2024 04:09 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ANAHEIM VILLA
FACILITY NUMBER: 306006387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87705(k)(4)

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87705(k)(4)CARE OF PERSONS WITH DEMENTIA (4) Without violating Section 87468, Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility.
Based on incident report submitted to licensing and interview with Administrator
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AD stated that they will conduct in-service training with facility staff to ensure staff understands how to properly supervise dementia residents. AD stated that, by the POC due date, they will email LPA documentation indicating the attendees, date(s) of the training and topics covered.
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the facility did not comply with the section cited above due to the fact that one dementia resident left the facility unsupervised.
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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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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